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Understanding How Minority Stress, Gender Identity, and Resilience Predict Psychological
Distress Among Asexual Transgender and Gender Non-Conforming Individuals
by
Jared W. Boot-Haury
A DISSERTATION
Submitted to
Michigan School of Psychology
in Partial Fulfillment of the Requirements
for the Degree of
Doctor of Psychology
October 2022
This dissertation was approved by the doctoral committee:
Danielle Balaghi, PhD, Committee Chair
Dustin Shepler, PhD, Faculty Advisor
Lauren McInroy, PhD, Consultant
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS i
Abstract
The presence of minority stress has been well documented among members of the transgender
and gender non-conforming community, as has the effect of resilience on buffering the impact of
minority stress on their psychological distress. Little attention has been given to transgender and
gender non-conforming people who identify as asexual. This study examined the relationships
among minority stressors, resilience, and psychological distress among individuals holding the
intersecting identities of transgender and gender non-conforming and asexual. Data were
collected from 300 adults using various listservs and social media platforms. Significant
differences in harassment & discrimination χ2(2) = 7.27, p = .026 were reported by individuals
holding an intersecting asexual and transgender and gender non-conforming identity. Post hoc
analysis using Kruskal-Wallis tests did not reveal any significant differences. Therefore, while
there may be a significant difference in harassment & discrimination, it is unclear where that
difference lies. Multiple regression results revealed that vigilance and gender expression
minority stress were significant positive predictors of psychological distress, F(11, 258) = 10.21,
p < .001, f2 = .43; the overall model accounted for approximately 30% (R2 = .30) of the total
variance in psychological distress. Resilience was a significant negative predictor of
psychological distress but did not moderate the relationship between minority stress, gender
identity, and psychological distress. Implications for practice and research are discussed.
Keywords: transgender, gender non-conforming, asexual, intersectionality, minority
stress, resilience, psychological distress
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS ii
Dedication
This work is dedicated to the asexual and transgender and gender non-conforming
communities; may their resilience help them thrive despite living in an unjust world.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS iii
Acknowledgements
Thank you to everyone who supported me throughout this challenging and rewarding process.
Dr. Balaghi, I am thankful for your dedication, guidance, and most importantly, your steadfast
and caring commitment to helping me achieve excellence throughout my graduate education.
Thank you to everyone who has supported me throughout this challenging and rewarding
process. Thank you to my mentor through APA’s LGBTQIA+ Mentoring Program, Dr. Jonathan
Mohr, for his gentle and kind guidance on some of the more complex technical components of
the dissertation process. Thank you to my advisor through George Washington University's
LGBT Health Policy and Practice Graduate Certificate program, Kat Carrick, for supporting me
when setbacks made completing the dissertation process seem unimaginable. Lastly, but most
importantly, thank you to my husband, Aaron Boot-Haury, for his love, emotional support, and
encouragement, which helped shape me into the early career professional I am today.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS iv
Table of Contents
Abstract ............................................................................................................................................ i
Dedication ....................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iii
Chapter I – Introduction .................................................................................................................. 1
Introduction to the Transgender and Gender Non-Conforming and Asexual Communities ...... 1
Clinical Relevance ...................................................................................................................... 8
Social Relevance ....................................................................................................................... 11
The Current Study ..................................................................................................................... 13
Chapter II – Review of the Literature ........................................................................................... 15
Theoretical Framework ............................................................................................................. 15
Asexual Identity ........................................................................................................................ 23
TGNC Identity .......................................................................................................................... 25
Intersectional Identity: Asexual and TGNC ............................................................................. 26
Social Context ........................................................................................................................... 27
Psychological Distress in Asexual, TGNC, and Asexual TGNC Individuals .......................... 31
Distal and Proximal Stressors for Asexual, TGNC, and Asexual TGNC Individuals.............. 35
Resilience in Asexual, TGNC, and Asexual TGNC Individuals .............................................. 47
Summary and Present Study ..................................................................................................... 54
Chapter III – Research Model, Methods, and Procedures ............................................................ 61
Methodological Design ............................................................................................................. 61
Participants................................................................................................................................ 62
Sampling Procedures ................................................................................................................ 63
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS v
Measures ................................................................................................................................... 65
Analytic Strategy ...................................................................................................................... 72
Chapter IV – Presentation of Findings.......................................................................................... 75
Missing Data ............................................................................................................................. 75
Preliminary Analyses ................................................................................................................ 79
Main Analyses .......................................................................................................................... 82
Post Hoc Kruskal-Wallis H Tests ............................................................................................. 92
Chapter V – Discussion and Conclusions ..................................................................................... 93
Discussion of Findings.............................................................................................................. 93
Limitations .............................................................................................................................. 102
Directions for Future Research ............................................................................................... 104
Clinical, Social, and Theoretical Implications ........................................................................ 107
Conclusion .............................................................................................................................. 111
References ................................................................................................................................... 113
Appendix A ................................................................................................................................. 143
Appendix B ................................................................................................................................. 144
Appendix C ................................................................................................................................. 146
Appendix D ................................................................................................................................. 147
Appendix E ................................................................................................................................. 149
Appendix F.................................................................................................................................. 151
Appendix G ................................................................................................................................. 152
Appendix H ................................................................................................................................. 153
Appendix I .................................................................................................................................. 154
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 1
Chapter I – Introduction
Introduction to the Transgender and Gender Non-Conforming and Asexual Communities
Transgender, Gender Non-Conforming Terminology
The terms sex and gender are often conflated. Sex is a “biological medical term referring
to a certain combination of gonads, chromosomes, external gender organs, secondary sex
characteristics, and hormonal imbalances” (Mukerjee et al., 2021, p. 23). Based on those
attributes, individuals have historically been given a sex assigned at birth (SAAB) of male or
female. However, there is growing awareness of intersex individuals who do not have
reproductive and sexual anatomy that fit within the binary of male-female (Mukerjee et al.,
2021). According to Mukerjee et al., delineating sex and gender identity using the phrase SAAB
is consistent with a transgender-affirmative approach to client care. Gender identity is defined as
“an internal personal identification with cultural definitions of masculinity/man/boy/male,
femininity/woman/girl/female, as well as neither, both, or other gender[s]” (Mukerjee et al., pp.
23-24). Cisgender is a term used to refer to those who have a gender identity aligned with their
SAAB (Serano, 2006). The term transgender is a broad umbrella phrase that describes
individuals who have a gender identity that diverges from their SAAB (American Psychological
Association, 2013). The term gender non-conforming includes those whose gender identity exists
on a continuum rather than existing on a gender binary and includes identities such as
genderqueer, gender fluid, non-binary, and agender (Fassinger & Arseneau, 2007). The
transgender and gender non-conforming communities are denoted by the acronym, TGNC.
TGNC Community
TGNC people can take numerous risks and face extensive societal stigma by living
authentically as their self-identified gender identity. This stigma increases the likelihood of
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 2
TGNC people experiencing microaggressions or “brief, everyday exchanges that send
denigrating messages to certain individuals because of their group membership (Sue, 2010, p.
xvi). Microaggressions are considered a tacit contemporary form of discrimination because of
their denigrating tone (Sue, 2010). Up to 54% of TGNC people experience microaggressions
related to verbal harassment each year (James et al., 2016). Microaggressions can result in
psychological dysfunction and adverse mental health outcomes for TGNC individuals.
TGNC individuals face unique challenges and daily gender identity-related stressors,
putting them at risk of negative mental health consequences (Borgogna et al., 2018; James et al.,
2016). Lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) people often
face disproportionate stigma relative to their cisgender heterosexual peers. In recent years, up to
32% of the LGBTQIA community have reported either experiencing being told they were
unwelcome or feeling unwelcome (Casey et al., 2019). In contrast, up to 86% of the transgender
and gender non-conforming (TGNC) community report experiencing either being told they were
unwelcome or feeling unwelcome. Similarly, 86% of TGNC people consider moving to another
area because of personally experienced discrimination, whereas only 31% of the overall
LGBTQIA community make the same consideration. Thus, members of the TGNC community
appear to be at a disproportionate risk of discrimination and stigma compared with the broader
LGBTQIA community. Higher discrimination and stigma may increase the risk of poor mental
health; prior research has shown higher rates of depression, anxiety, suicide, and self-harm in the
TGNC community than among cisgender counterparts of any sexual orientation (Meier &
Labuski, 2013).
Some research indicates that differences may exist in minority stress and psychological
distress based on TGNC individuals’ SAAB (Bockting et al., 2013; Hendricks & Testa, 2012).
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 3
Specific study findings indicate that individuals in the TGNC community assigned female at
birth (AFAB) may experience higher rates of sexual abuse and domestic violence than those
assigned male at birth (AMAB; Rimes et al., 2019; Sterzing et al., 2019). Yet, there may be
higher psychological distress among GNC individuals who were AMAB compared to those
AFAB, because those individuals affirming their gender identity may be construed as defying
social scripting associated with masculinity (Chavanduka et al., 2020).
Asexual Terminology
Not all asexual individuals consider themselves to be part of the broader LGBTQIA
community. For instance, those who are cisgender and heterosexual may eschew being labeled as
part of the LGBTQIA community (Mollet & Lackman, 2018). Allosexuality consists of
individuals who have typical amounts of sexual attraction to one or more groups of people
(Fuller, 2020). While researchers continue to debate the specific definition of asexuality, asexual
people include either individuals who experience divergent amounts of sexual attraction relative
to allosexual individuals or individuals with an absence of sexual attraction (Chasin, 2011).
Asexuality is an emerging research topic that is not vigorously defined due to the historical lack
of research on asexual identity. Despite minor research attention, researchers have long known
that people who do not desire sex or experience sexual attraction to others exist (Milks &
Cernakowski, 2014).
Asexual Community
Yule et al. (2013) suggests that “asexual individuals may face the same social stigma
experienced by gay, lesbian, and bisexual persons” (p. 136). Yule et al. posit that asexual people
deviating from conventions that disproportionately emphasize sexual activity may be
substantially more likely to experience minority stress; however, studies focused on minority
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 4
stress of asexual individuals could not be located. However, in a recent study, asexual people
report higher Patient Health Questionnaire-9 and General Anxiety Disorder-7 scores than those
among the overall LGBTQIA community, perhaps due to minority stress (Borgogna et al., 2018).
Higher levels of depression and anxiety may be indicative of minority stress.
Asexual people also experience subtle microaggressions (MacInnis & Hodson, 2012),
which may cause higher rates of minority stress and result in adverse mental health outcomes
(Borgogna et al., 2018; Yule et al., 2013). About 48% of asexual people report attempts by
others to change their sexual orientation, while 20% experience exclusion from social activities
(Weis et al., 2020). Nearly half of asexual people may experience microaggressions, such as
being asked inappropriate personal questions, and up to 31% may experience verbal harassment
because of their identity (Weis et al., 2020). Stigma and discrimination, especially in the form of
microaggressions, are common for asexual individuals.
Asexual communities have become increasingly visible due to sociopolitical changes
over the past decade. Researchers have responded to this increase in visibility by beginning to
call attention to the problematic nature of assuming sexual desire is universally experienced by
all adults (Flore, 2014; Mitchell & Hunnicutt, 2018; Scherrer, 2008). Thus, recent research has
shifted the conceptualization of asexuality, and intersectional identities, such as those who are
both asexual and TGNC, are being explored (Vincent, 2018).
Intersectional Asexual TGNC Community
Intersectionality deals with understanding people of co-occurring marginalized identities
and identifying their “unique vulnerability [to] converging systems of domination” (Crenshaw,
1995, p. 367). Those who are asexual and TGNC hold an intersectional identity as both a gender
minority (i.e., TGNC) and a sexual minority (i.e., asexual). People with intersecting sexual and
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 5
gender minority identities (i.e., asexual TGNC people) may have a cumulative and significantly
higher rate of minority stress compared to cisgender sexual minority (e.g., asexual) people
(Williams et al., 2020).
Asexual TGNC people may be especially susceptible to stigma compared to the overall
LGBTQIA community (McInroy et al., 2020). In addition to the stigma experienced by the
LGBTQIA community from people outside of that community, stigmatizing experiences for
asexual people within the LGBTQIA community are not uncommon (Cuthbert, 2019).
According to Cuthbert’s qualitative analysis, asexual TGNC people often feel reticent to disclose
their combined gender and sexual minority experience to the broader LGBTQIA community due
to the discrimination they may experience within that community.
Asexual TGNC people may feel unsafe seeking out community support from the
LGBTQIA community, thereby missing out on the potential protective factor of community
connectedness on minority stress (Cuthbert, 2019; Dawson et al., 2018; Mollet & Lackman,
2018). Essentially, minority stressors related to TGNC minority stress may be compounded when
coupled with asexual minority stressors (Gamarel et al., 2014; Gupta, 2015; Rachlin, 2019).
Minority stress may be even higher for those identified as asexual TGNC because asexual people
experience disproportionate mental distress relative to those holding a single identity within the
LGBTQIA community (Borgogna et al., 2018; McInroy et al., 2020; Williams et al., 2020).
While minority stress is known to be linked to poor mental health, there is a shortage of
literature investigating the intersection of asexual TGNC adults' relationship between minority
stress and mental health. Only one study by McInroy et al. (2020) addresses this topic. In
McInroy et al.’s research, asexual TGNC individuals reported higher rates of internalized
stressors (e.g., self-perceived stress and internalized LGBTQIA-phobia) than allosexual (non-
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 6
asexual) peers. Other research has also shown that internalized lesbian, gay, and bisexual (LGB)-
phobia (Herek, 2009), lesbian, gay, bisexual, and transgender (LGBT)-phobia (Newcomb &
Mustanski, 2010), and LGBTQIA-phobia (Puckett et al., 2019) are linked to mental health
difficulties. The asexual young adult and adolescent participants in the study by McInroy et al.
(2020) also have poorer mental health than their allosexual peers (e.g., higher rates of depressive,
anxious, and somatic symptoms, and higher suicidal ideation). However, unlike their allosexual
peers, asexual individuals have lower levels of externalizing behaviors (e.g., substance abuse and
suicide attempts). Individuals with multiple stigmatized identities may experience various forms
of stigma and discrimination, the effects of which may not be understood by studying each
identity in isolation (Mink et al., 2014).
Historically, gender and sexual minority research has primarily focused on minority
stress rather than protective factors that can buffer the experience of minority stress (Kwon,
2013). This emphasis on minority stress comes at the expense of understanding identity-related
resilience, which has led to a predominantly negative view of the state of gender and sexual
minority communities (Meyer, 2015).
Resilience is adaptive functioning when a person experiences stress (Masten, 2007;
Meyer, 2015). Adaptive functioning is identified as the capacity to recover from hardships and
demonstrate stress resistance under adverse conditions (Masten, 2007). Furthermore, resilience
encompasses positive development, even in the context of heightened aggregate probability for
developmental complications (Masten, 2007). Resilience is thought to buffer minority stress in
one of two ways: through protective factors that offset risk or through promotive factors that
moderate risk (Meyer, 2015; Wheaton, 1985).
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 7
Recent literature on sexual and gender minorities indicates that resilience is significantly
associated with belonging to a community with robust connections to others and having
affirmative role models (Brotto & Yule, 2009; Brotto et al., 2010; Fredriksen-Goldsen et al.,
2013; Gonzalez et al., 2012; Gupta, 2018; Riggle et al., 2008, 2011; Rostosky et al., 2010;
Trujillo et al., 2016). The same literature also indicates a positive association between identity-
related stigma and psychological distress. The research mentioned above includes individuals
belonging to various sexual minority groups, including those who identify as asexual (Brotto &
Yule, 2009; Brotto et al., 2010; Gupta, 2018). Similarly, this research includes individuals
belonging to various gender identity groups, such as those who identify as GNC individuals
(Fredriksen-Goldsen et al., 2013; Gonzalez et al., 2012; Riggle et al., 2011; Trujillo et al., 2016).
However, the resilience of intersectional asexual TGNC individuals has not been explored.
Although initial research examined minority stress and psychological distress among
asexual TGNC adolescents and young adults (McInroy et al., 2020), resilience factors have not
been investigated. Research is needed to investigate the interaction between resilience factors
and minority stress in asexual TGNC individuals. Although literature regarding resilience among
intersectional asexual TGNC individuals who experience multiple stressors (e.g., combined
sexual orientation and gender identity stigma) indicates that the level of individual resilience
among asexual TGNC individuals could be limited (Singh & McKleroy, 2010), there may also
be an opportunity to facilitate resilience (White, 2014). White argues that this could be done by
facilitating intersectional community belongingness and support among individuals who identify
as TGNC and as a member of another minority community (i.e., a person of color). Like the
studies regarding other intersectional identities, such as TGNC people of color, that show factors
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 8
like social support conferred resilience buffering psychological distress, resilience could be a
crucial factor for buffering psychological distress in the asexual TGNC community.
Clinical Relevance
This research aims to provide health professionals from different disciplines with some
understanding of minority stress in people with the intersecting identities of asexual and TGNC.
This understanding can provide clinicians with the information and insights necessary to provide
LGBTQIA-affirmative treatment, which is linked to better treatment outcomes (Lambert &
Barley, 2001; Lelutiu-Weinberger & Pachankis, 2017; Pepping et al., 2018). In affirmative
therapy, sexual and gender diversity are seen as normal variants of human gender and sexuality
that do not require change (Davies, 1996; Pachankis & Goldfried, 2004; Pepping et al., 2018;
Shelton & Delgado-Romero, 2011). Furthermore, affirmative therapy recognizes contextual and
systematic influences that result in minority stress and affect sexual and gender minority clients’
well-being (Meyer, 2003; Testa et al., 2015).
Without affirmative therapy amplifying resilience factors that act as buffers, distal
stressors (e.g., victimization and harassment & discrimination) lead to more proximal stressors
(e.g., isolation and vigilance). These stressors, in turn, lead to adverse health outcomes,
especially when negative coping behaviors (e.g., substance abuse) take the place of protective
factors like peer and family support and identity pride (Chavanduka et al., 2020). If health
professionals take an affirming treatment stance and are aware of accessible resilience factors for
clients, they can help clients access those resources using techniques such as motivational
interviewing. Similarly, if health professionals are aware of minority stressors and their effects
on psychological distress for TGNC asexual clients, they can help clients with targeted
therapeutic techniques and treatments to mitigate their distress.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 9
TGNC people often experience difficulty accessing protective factors, such as peer
groups and familial support, which increases the likelihood of negative coping behaviors and
heightens feelings of isolation and marginalization (Gridley et al., 2016; Olson et al., 2015). This
makes it particularly difficult for individuals to cope with stress and to have positive health
outcomes (Chavanduka et al., 2020). With the increase in online support groups and resources
resulting from the COVID-19 pandemic, perhaps therapists can help this marginalized
community leverage resources that may have proved more difficult to access in the past (Jones et
al., 2021).
TGNC people who also identify as a sexual minority (i.e., LGB, “other,” or “don’t
know”) have increased odds of having poorer health outcomes than heterosexual transgender
adults (Cicero et al., 2020). Therefore, coupling a further marginalized sexual minority identity
than studied by Cicero et al. (2020), specifically asexuality, may further increase the risk of
poorer health outcomes. According to Cicero et al., clinicians adopting an intersectional,
socioecological approach to work with TGNC individuals may be critical for improving TGNC
health outcomes.
Studies have illustrated the correlation between minority stressors and psychological
distress (e.g., anxiety, depression, self-injury, and suicidal ideation and attempts) among gender
and sexual minorities (Meyer, 2003; Testa et al., 2015). Specifically, distal stressors such as
experiencing prejudice and discrimination are associated with higher psychological distress
among TGNC individuals (Bockting et al., 2013). Additionally, gender-related discrimination
and victimization tend to be associated with an increased risk of suicide attempts (Clements-
Nolle et al., 2006; Testa et al., 2012). Less research has focused on resilience factors and the role
of proximal stressors in the psychological distress of TGNC individuals (Testa et al., 2015).
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 10
Similarly, research has not sufficiently focused on intersectional gender and sexual minorities
and the interplay between proximal stressors, distal stressors, and resilience. The lack of an
intersectional focus on exploring minority stress, resilience, and their impact on psychological
distress is especially apparent in research on asexual individuals (Guz et al., 2022).
An ability to identify differences in minority stress and resilience among gender non-
conforming (GNC) individuals, transgender women (TGW), and transgender men (TGM) may
help therapists provide affirming and culturally competent care that facilitates improved
resilience and mitigates the effects of minority stress (James et al., 2016; Poquiz et al., 2021).
TGNC patients can critically benefit from readily accessible, culturally competent healthcare and
social support (Bockting et al., 2013; Farrell, 2018; Gower et al., 2018). Clients with affirming
providers may have lower rates of depression, suicidal ideation, and anxiety (Butler et al., 2019;
Kattari et al., 2016). Therefore, it is crucial for providers to have more exposure and education
regarding gender and the TGNC community to increase treatment adherence and minimize
treatment withdrawal (Frohard-Dourlent et al., 2017). There are relatively few ways in formal
professional education for clinicians to gain exposure and education to improve knowledge,
skills, and awareness regarding LGBTQIA identities (Lelutiu-Weinberger & Panchankis, 2017;
Pratt-Chapman et al., 2022). However, outcome studies show that training outside of formal
clinician education programs can improve competency in knowledge, skills, and awareness and
facilitate the provision of LGBTQIA affirmative treatment (Bidell, 2013; Leyva et al., 2014;
Lelutiu-Weinberger & Panchankis, 2017; Pepping et al., 2018).
Lack of clinician awareness and sensitivity to asexual individuals and their intersectional
identities (e.g., asexual TGNC people) may negatively impact rates of using college counseling
services among individuals holding intersecting gender and sexual minority identities compared
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 11
to individuals holding only a sexual minority identity (McAleavey et al., 2011). The lower use of
mental health services among LGBTQIA people may be related to perceived prejudice (e.g.,
anti-asexual prejudice) and the perception among potential clients of an elevated risk of over-
pathologization from practitioners (Foster & Scherrer, 2014). Asexual people in particular are
prone to facing distinct difficulties in obtaining asexual affirmative mental health services
(Gupta, 2018). These difficulties include attempted conversion therapy, misdiagnosis, and
pathologization of asexual identity (Conley- Fonda & Leisher, 2018; Hinderliter, 2013; Yule et
al., 2017). TGNC individuals also face difficulty accessing affirmative mental health services
because of systematic discrimination and transphobia (dickey et al., 2016; Kcomt et al., 2020),
which puts them at a higher risk for various physical and mental health issues (Feldman et al.,
2016). These difficulties highlight the importance of further research and awareness of specific
stressors, resilience factors, and psychological distress among asexual TGNC individuals.
Social Relevance
Some segments of the overall community of sexual and gender minority individuals may
face more barriers to community connection than others, which limits opportunities for
community connection and resilience (Meyer, 2015). Data suggest that asexual people comprise
1% of the general population, but 10% of the overall TGNC population (Bogaert, 2004; James et
al., 2016; Miller, 2011). Because asexual people are more likely to hold intersecting sexual and
gender minority identities, enhancing the social climate of the LGBTQIA community for asexual
people may be particularly important. There is a disproportionate population of TGNC asexual
people relative to the overall population. Due to the centrality of community connectedness in
resilience for both asexual and TGNC people, and the health disparities associated with an
intersectional asexual TGNC identity, enhancing the social climate of the LGBTQIA community
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 12
may be particularly important for TGNC (Bariola et al., 2015; Budge et al., 2013) and asexual
individuals (Brotto & Yule, 2009; Van Houdenhove et al., 2017). Ways to do this include
increasing public awareness to combat myths and misinformation, passing nondiscrimination
policies to protect against discrimination, implementing parenting campaigns to improve family
acceptance, and improving the climate at schools and colleges to prevent discrimination and
promote resilience among LGBTQIA youth (Gower et al., 2018; McInroy et al., 2020; Mollet &
Lackman, 2018; Simon et al., 2021).
Younger generations of LGBTQIA youth are increasingly identifying as asexual, TGNC,
and asexual TGNC (The Trevor Project, 2020). In a recent sample of over 40,000 LGBTQIA
young people, 34% of respondents identified as transgender, non-binary, or questioning, and
10% of the respondents identified as asexual (Trevor Project, 2020). Among those who identified
as asexual, 54% identified as transgender, non-binary, or questioning. Because of the
disproportionate number of asexual individuals who identify as TGNC and the history of
exclusion within LGBTQIA communities, asexual people can experience erasure and stigma
from LGBTQIA communities instead of support (Cuthbert, 2019; Dawson et al., 2018; Mollet &
Lackman, 2018). Increased visibility and less stigmatization of asexuality at LGBTQIA
community centers (e.g., offering asexual support groups and resources) may help improve
community connectedness and resilience among asexual TGNC people. An improved climate at
LGBTQIA community centers could lessen the high possibility of experiencing exclusion and
harassment when attempting to connect with others in those settings (Cuthbert, 2019; Sumerau,
2018). The need for more visibility and inclusion is why the work of organizations such as The
Ace and Aro Advocacy Project and guidelines outlined by APA (2021), which incorporate the
latest research on asexuality and intersectionality among sexual minority persons, are so
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 13
important. If visibility increases, thereby increasing opportunities for enhanced connection and
resilience and decreasing opportunities for minority stress, this may result in better health
outcomes and a less-taxed mental health system (Badgett et al., 2019).
The Current Study
Informed by the concepts of intersectionality, minority stress theory, and resilience
theory, the aims of the present study were threefold. First, I examined how gender expression,
minority stress, proximal (vigilance and isolation), and distal (harassment & discrimination and
victimization) minority stressors relate to psychological distress in asexual TGNC individuals.
Secondly, I examined whether resilience moderates the relationship between minority stressors
and psychological distress. Lastly, I assessed whether resilience moderates the relationship
between gender identity, gender expression minority stress, proximal and distal minority
stressors, and psychological distress. Thus, the following research questions were addressed in
the present study:
1. Do proximal (vigilance and isolation), distal (harassment & discrimination, and
victimization), and gender expression minority stress predict psychological distress
among asexual TGNC individuals?
2. Does resilience moderate the relationship between psychological distress and
proximal (vigilance and isolation), distal (harassment & discrimination, and
victimization), and gender expression minority stress among asexual TGNC
individuals?
3. Does resilience significantly differ in relation to gender identity among asexual
TGNC individuals?
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 14
4. Do proximal (vigilance and isolation), distal (harassment & discrimination and
victimization), and gender expression minority stress significantly differ in relation to
gender identity among asexual TGNC individuals?
5. Does psychological distress significantly differ in relation to gender identity among
asexual TGNC individuals?
6. Does resilience moderate the relationship between proximal (vigilance and isolation),
distal (harassment & discrimination and victimization), gender expression minority
stress, gender identity, and psychological distress among asexual individuals?
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 15
Chapter II – Review of the Literature
In this chapter, a theoretical framework for the literature review is first presented. Then, a
historical overview of asexuality, TGNC, and asexual TGNC descriptions and demographics is
presented. Next, a summary of the societal context, discrimination, and oppression for each of
the three identity groups is described. After that, an overview of psychological distress, minority
stress, and resilience within the context of each identity group is presented. The purpose of this
review is to summarize research on asexual, TGNC, and intersectionally asexual and TGNC
people within the framework of minority stress theory (e.g., the mental health consequences
experienced by each group and how resilience and minority stress impact psychological distress).
Similarities and differences between groups and research describing resilience, distal and
proximal minority stress, and their consequences on well-being and psychological distress are
presented for asexual, TGNC, and asexual TGNC people.
Theoretical Framework
Intersectionality
Initial attention to intersectionality originated from Crenshaw (1995), who coined the
term to label a framework that challenges the view that race and gender are mutually exclusive
categories. Intersectionality also involves consideration of other identities, such as sexual
orientation. Originally, Crenshaw (1995) conceptualized the intersectional experience of women
living in poverty to explore the co-occurring societal oppression against people living in poverty,
women, and people of color in America. She posited that racial discrimination compounded the
consequences of gender and class oppression (specifically related to domestic violence).
Furthermore, she argued that social welfare interventions targeted solely at women without
considering socioeconomic status and race would not be successful in helping women who hold
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 16
intersecting identities of being a woman and a person of color. In essence, Crenshaw (1995)
argued against essentializing individual identities and argued instead for considering the diverse
experiences of those who live at the margins (i.e., have multiple intersecting minority identities).
While intersectionality was initially applied as a legal and policy argument, its goal of centering
marginalized identities had implications for psychology and other disciplines.
The concept of intersectionality has recently been applied in research on gender and
sexual minority populations. The use of this framework has helped make sense of some of the
mental challenges associated with negotiating multiple intersecting stigmatized identities for
sexual and gender minorities (Cochran & Mays, 2016; Wallace & Santacruz, 2017). Although
research is limited on intersecting gender and sexual minority identities, initial findings suggest
worse psychological outcomes than those with a single LGBTQIA minority identity (Williams et
al., 2020). Williams et al. contend that this may be due to the relatively higher contact with
minority stressors for those who hold both sexual and gender minority identities. Little research
has been conducted on the intersection between asexuality and TGNC identities. This research
gap may relate to the highly sexualized culture in America and the tendency to view asexual
individuals more negatively than other sexual minority subgroups (MacInnis & Hodson, 2012;
Sumerau et al., 2018; Yule et al., 2013).
Researchers have investigated the intersection of different forms of identity, such as
sexual orientation and race, or gender identity and race. For example, studies have shown a
negative relationship between racist and heterosexist stigma and discrimination and mental
health among Latinx sexual minority individuals (Velez et al., 2014). Specifically, the authors
found that individuals who experienced high internal stress related to one identity (e.g., sexual
identity) had exacerbated poor self-esteem when facing high external stress related to another
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 17
identity (e.g., race). Another study found that Black sexual minority women had a higher
frequency of discrimination, a broader set of types of discrimination, and poorer psychological
well-being than White sexual minority women (Calabrese et al., 2014). Calabrese et al.
contended that various mental health disparities are related to heightened exposure to
discrimination because Black sexual minority women hold multiple marginalized identities.
Despite the mental health struggles and psychological vulnerabilities associated with
intersecting stigmatized identities, some people with intersecting stigmatized identities may
display psychological resilience. For instance, Greene and Spivey (2016) highlighted that trans
people of color display resilience through intersectionality-facilitated resilience. In this process,
coping strategies used specifically for experiences related to one marginalized identity (racial
identity) are transferred to another marginalized identity (gender identity) to maintain a healthy
and unified identity. Similar research has shown that Black LGB individuals fared better than
LGB White individuals because of their ability to transfer coping strategies related to their
experiences of racial discrimination to situations involving sexual discrimination (Meyer, 2010).
Due to the complexity and nuance of diverse LGBTQIA populations (i.e., their experiences of
psychological vulnerability or psychological resilience resulting from incidents of heterosexism,
genderism, and racism), researchers have argued that research with an intersectional focus is
necessary for the public health of LGBTQIA populations (Bowleg, 2012; Cole, 2009).
Minority Stress and Gender Identity Minority Stress Theory
Building on Zuckerman’s (1999) diathesis-stress model, Meyer’s (2003) minority stress
theory, as indicated in Figure 1, suggested that added psychological stress could lead to
psychological dysfunction. Minority stress can be distal and can occur through various external
events, such as societal stigma and prejudice (Meyer, 2003; Testa et al., 2015). Minority stress
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 18
can also be proximal and occur through various internal events, such as anticipatory anxiety,
identity concealment, and hypervigilance. Prejudice based on one’s sexual or gender identity can
then be internalized, and psychological distress is more likely to be experienced. While empirical
findings supporting minority stress were initially derived from studies on gay men, the model
was expanded to include lesbians and gay men (Meyer, 1995), bisexual men and women (Meyer,
2003), and LGB people of color (Meyer, 2010). Hendricks and Testa (2012) hypothesized that
the minority stress model could also be applied to clinical work with TGNC clients. Testa et al.’s
(2015) research expanded Meyer’s minority stress model to account for gender minority stress
and resilience. The model, as indicated in Figure 2, showed that in people who identify as
TGNC, stigmatizing experiences heightened minority stress; however, resilience factors could
act as a buffer for minority stress.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 19
Figure 1
Minority Stress Processes in Lesbian, Gay, and Bisexual Populations
Note. From “Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations:
Conceptual issues and research evidence,” by I. H. Meyer, 2003, Psychological Bulletin, 129(5),
p. 8 (https://doi.org/10.1037/0033-2909.129.5.674). Copyright 2003 by the American
Psychological Association. Reprinted with permission.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 20
Figure 2
Minority Stress and Resilience Factors in Transgender and Gender Non-Conforming People
Note. From “Development of the gender minority stress and resilience measure,” by R. J. Testa,
J. Habarth, J. Peta, K. Balsam, and W. Bockting, 2015, Psychology of Sexual Orientation and
Gender Diversity, 2(1), p. 67 (https://doi.org/10.1037/sgd0000081). Copyright 2015 by the
American Psychological Association. Reprinted with permission.
The TGNC population has often been studied as a homogeneous group. Recently,
researchers such as Stanton et al. (2021) suggested distinguishing within subgroups to cater to
specific needs. Stanton et al. distinguished between TGW, TGM, and non-binary individuals.
Lefevor et al. (2019) extended gender minority stress theory by identifying minority stress
unique to GNC individuals. Their findings revealed heightened and unique stressors that
influence the psychological well-being of GNC individuals. Specifically, GNC individuals could
be more likely to experience anxiety, depression, psychological distress, eating concerns, self-
harm, and suicidality. Minority stress theory has also been used as a framework to examine the
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 21
psychological well-being of emerging identities, such as asexual individuals, in the LGBTQIA
community. Like other emerging identities in sexual and gender minority communities, asexual
people may experience “greater identity unique stress due to holding a minority status within the
LGBTQIA community” (Borgogna et al., 2018, p. 55), which puts them at greater risk for
prejudice and stigma. Additionally, Cuthbert (2019) pointed out that it is common for asexual
TGNC people to face prejudice and feel excluded within the LGBTQIA community because the
LGBTQIA community tends to emphasize the separation of sexuality and gender identity. This
emphasis is due to the historical and stigmatizing conflation of gender identity and sexual
identity, which resulted in LGBTQIA misrecognition and erasure. Consequently, an
intersectional asexual TGNC identity tends to be viewed as problematic by the LGBTQIA
community. There is empirical support for the idea of a synergetic effect between having both a
gender minority identity and a sexual minority identity, where mental health struggles were
higher for intersectional gender and sexual minorities than for those holding a minority sexual or
gender identity alone (Borgogna et al., 2018).
While recent research on the asexual community has broadly increased, no studies have
explicitly shown that minority stress affects asexual people, as it does other sexual and gender
minorities (Guz et al., 2022). There have been mixed results in studies on psychological distress
among asexual respondents. Some research showed higher psychopathology rates among asexual
respondents (Borgogna et al., 2018; Yule et al., 2013). Yet, other researchers have found that
asexual individuals have no notable signs of psychopathology relative to allosexual individuals
(Bauer et al., 2019; Brotto et al., 2010). Therefore, more research is needed to ascertain whether
minority stress positively predicts psychological distress in asexual individuals, similar to other
sexual and gender minority communities.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 22
Resilience Theory
Originally, resilience theory was conceptualized as a characteristic associated with youth
that could guide prevention efforts and social policies to mitigate the risk of adversity on
development (Yates & Masten, 2004). Resilience theory is increasingly being applied to adult
development in minority communities under adverse conditions, especially regarding gender and
sexual minority individuals (Bockting et al., 2013; Figueroa & Zoccola, 2015; Woodford et al.,
2018). The foundation for developing resilience is positive adaptation to life challenges and
overcoming situations that cause significant adversity (Masten & Reed, 2002). Protective factors
associated with resilience include the characteristics of an individual, their family, and their more
extended community ecosystem that lessen the adverse consequences of adversity, and strategies
to promote resilience may focus on increasing protective factors (Masten & Reed, 2002). Risk
factors are also associated with resilience, including stressful and adverse events (e.g., crime and
health conditions). Masten and Reed highlighted the importance of strategies to promote
resilience, which may also focus on risk reduction to avoid negative health consequences of
adversity.
Perhaps the mixed findings presented above regarding psychological distress in
LGBTQIA individuals have to do with what Meyer (1995) called minority coping effects, which
act as buffers for minority stress. Similar to the resilience factors identified above, Meyer (2003)
and Testa et al. (2015) noted that some protective factors might reduce stress via increased group
solidarity and increased self-acceptance, contributing to increased psychological well-being and
resilience. Resilience among asexual individuals appears to be related to community
connectedness (Brotto & Yule, 2009; Van Houdenhove et al., 2017). Although the effect of
community connectedness on asexual individuals’ minority stress has not been studied directly,
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 23
some studies have delineated a potential relationship (albeit indirectly). For instance, self-esteem,
a resilience factor often linked to community connectedness (Zimmerman et al., 2015), may
buffer stress among asexual individuals (Brotto et al., 2010; Brotto & Yule, 2009). People in
communities with high collective self-esteem could be more likely to demonstrate resilience.
Another indirect factor associated with resilience has been validating identity (Bruce et al.,
2015). Validating asexual identity also appears to be connected to resilience according to a
qualitative analysis in a systematic literature review (Jones et al., 2017).
Community connectedness through direct studies appears to be critical to resilience and
to buffering the association between gender-related stigma and psychological distress in TGNC
individuals (Fredriksen-Goldsen et al., 2013; Gonzalez et al., 2012; Singh et al., 2011; Trujillo et
al., 2016). Other factors, particularly positive reframing and letting go, seem to be important,
albeit to a lesser extent, for buffering minority stress (Budge et al., 2013). Because of the unique
intersectional risk factors associated with being asexual and TGNC (e.g., being a minority within
a minority community) and the consequent difficulties associated with community
connectedness, asexual TGNC individuals may have fewer opportunities to cultivate resilience
and self-esteem to buffer minority stress experiences (Cuthbert, 2019).
Asexual Identity
In addition to the 0-6 scale Kinsey and colleagues used for heterosexuality and
homosexuality [sic], respectively (1948), their scale included an “X” variable to denote those
without any sexual attraction to others. In contrast to Kinsey et al. (1948), who saw asexuality as
an anomaly existing outside the sexuality spectrum, Johnson (1977) described asexuality as
people who do not engage in sexual behavior and concurrently have an absence of sexual desire
(Kim, 2014). The first time that asexuality was distinctly featured as a valid and non-
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 24
pathologized sexual orientation was by Storms (1979, 1980, 1981). Storms described asexuality
as an orientation featuring a deficit of erotic fantasies and stimuli that arouse individuals. This
starkly differed from the conceptualization of asexuality as a continuum representing little to no
interest in sex (Chasin, 2011; Hille et al., 2019). While sexual desire may be diminished among
asexual individuals, it is crucial to note that recent literature has indicated that they may have a
wide variation in consensual sexual behaviors. Asexual orientation is not considered a clinical
term, and distress is not inherent in holding an asexual identity (Mukerjee et al., 2021). Instead,
asexuality represents normal variation in sexual orientation. Asexuality now exists more broadly
in the public consciousness.
Researchers who have studied asexuality have promulgated multiple competing
definitions to describe asexuality (Van Houdenhove et al., 2017). Some have defined people who
identify as asexual as people who experience little or no sexual attraction (Chasin, 2011). From
this perspective, asexuality is considered to be a sexual orientation that exists on a spectrum.
Asexuality has also been defined as an absence of sexual desire, which is a more binary or fixed
view of asexuality that labels people as either asexual or not asexual (Bogaert, 2006). Chasin’s
(2011) definition was used for this study.
Those who are asexual constitute approximately 1% of the population. Population
estimates for asexual people have remained stable over time (Bogaert, 2004, 2012; Kinsey et al.,
1948; Poston & Baumle, 2010). A census of the asexual community found that 56% of the
asexual community specifically used the term “asexual” to describe their orientation (Miller,
2011). Other participants in Miller’s (2011) analysis endorsed more nuanced identities that were
congruent with the view of asexuality as a spectrum. According to the 2011 Asexual Awareness
Week Community Census, terms like “demisexuality” (18%) and “greysexuality” (22%) were
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 25
used to define some asexual individuals. This is because many people within the asexual
community delineate the differences between sexual and romantic orientations (Hille et al.,
2019). Those who identify as demisexual may describe themselves as experiencing sexual
attraction only after establishing an intimate connection with another person (Decker, 2015).
Greysexual persons may define themselves as people who feel sexual attraction; however, that
attraction is relatively weak. Additionally, a greysexual person may experience periods of
endorsing sexual attraction to others and subsequent periods of not endorsing sexual attraction to
other people (Decker, 2015). The identification of various types of asexuality has highlighted the
broad and nuanced nature of the asexual community.
TGNC Identity
Historically, research on people who identify as TGNC began in 1910, with Magnus
Hirschfeld calling for studying gender and sexuality as separate constructs (Hirschfeld,
1910/2003). The term “transgender” was coined in the 1980s and differed from the previous
term, “transsexual,” which had negative connotations (Benjamin, 1966; Feinberg, 1996). Despite
attempts to reduce the negative connotations associated with transgender identity, transgender
people in the United States continue to be seen by many as outside what is considered
conventional. Consequently, they struggle with widespread stigma and discrimination (Bockting
et al., 2013; Grant et al., 2011; Lombardi et al., 2002).
Currently, the term “transgender” is conceptualized as “an umbrella term to describe
people whose gender expression or gender identity differs from gender norms associated with
their assigned birth sex” (American Psychiatric Association, 2013, p. 862). In other words,
transgender identity is now viewed as something that exists on a continuum, rather than
conceptualized as existing as a gender binary (Fassinger & Arseneau, 2007). More recently,
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 26
researchers have acknowledged that gender identity can fall outside the binary of male and
female, including GNC identities such as non-binary and genderqueer (Thorne et al., 2019b).
According to the 2011 Asexual Awareness Week Community Census, most people in the United
States who identify as TGNC identify with the broad term “transgender” (0.6%), whereas about
12% identify with other terms like “agender,” “genderqueer,” or “non-binary” (James et al.,
2016; Herman et al., 2016).
Historically, some researchers have assumed that transgender peoples’ experiences exist
within the binary gender construct, which can erase the experiences of some people who identify
as TGNC (Martin & Meezan, 2003). Current research on the TGNC community is still
challenging because the population is small, geographically dispersed, and stigmatized (Institute
of Medicine, 2011). Due to their historical stigmatization and oppression, people who identify as
TGNC may be less likely to self-disclose their gender identity to those outside the TGNC
community. This can make it difficult for researchers and psychologists to identify participants.
Intersectional Identity: Asexual and TGNC
Knowledge of the intersecting identities within the LGBTQIA community, such as those
of individuals who are both gender and sexual minorities, is limited. The intersecting identities of
asexual and transgender have been known for some time. However, views have shifted over
time. Harry Benjamin (1966) wrote that “many transsexuals [sic] have no overt sex life at all,
their sex drive being low to begin with” (p. 49). While it is notable that a high proportion of
asexual individuals within the TGNC community has long been recognized, Benjamin’s (1966)
views could be considered too broad and oversimplified today. Despite basic knowledge
regarding the disproportionate number of asexual individuals who also identify as TGNC, the
intersecting identity of being both asexual and TGNC remains understudied (Bauer et al., 2018;
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 27
Cuthbert, 2019; Greaves et al., 2016). More research is necessary to study the relationship
between gender and sexual orientation rather than siloing the two research areas (Cuthbert,
2019). At present, due to the dearth of research in understanding the intersection of TGNC and
asexual identities, the little that is known must be parsed out from more extensive studies that
have focused on LGBTQIA people overall.
The National Center for Transgender Equality conducted a large survey of transgender
people in America (the United States Transgender Survey [USTS]) and found that 10% of TGNC
individuals identified as asexual relative to 1% of the general population (James et al., 2016).
Other research also indicated that 10% of the asexual population identifies as transgender
(Miller, 2011), indicating a higher representation of asexual identity among TGNC people
compared to the general population. While there is a lack of research specifically related to the
intersecting identity of being asexual TGNC, other research exists related to the interaction of
being TGNC and holding another minority identity, which may be important to explore. Bogaert
(2012) noted that researchers have had many asexual survey respondents identify as
genderqueer, gender-neutral, and androgynous, and he and other researchers have called for
investigating the association between asexuality and gender identification (Brotto et al., 2010).
Social Context
Asexual people tend to face a negative social context, systemic oppression, and
devaluation, albeit in subtler forms, compared to the broader LGBTQIA community. For
instance, in religious contexts, harassment and discrimination may occur because of a perception
of asexuality as unnatural and going against the religious instruction to reproduce (Decker,
2015). Laws that allow for the annulment of marriages based on non-consummation imply that
marriage without sex is invalid, thereby suggesting that asexual people should not marry
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 28
(Bogaert, 2016). Additionally, asexual people may experience difficulties with bias that impacts
employment and housing due to being judged and rejected because they have atypical or non-
existent romantic relationships (MacInnis & Hodson, 2012). Asexual people are also at
heightened risk for “corrective rape” (i.e., rape motivated by the misguided belief that such
assault will align sexual orientation with heteronormative standards) even in the context of
marriage (Decker, 2015). Asexual individuals are largely invisible in media representations and
sex education. They are also subject to being prescribed harmful treatments for their identity, like
sexual arousal drugs or testosterone shots, by clinicians who generally lack cultural competence.
This is unsurprising because, despite specialist knowledge regarding the importance of
distinguishing between whether distress is associated with asexual identity or a lack of sexual
desire, the fifth and current edition of the Diagnostic and Statistical Manual includes no such
distinction for the diagnosis of disorders such as female sexual interest/arousal disorder or male
hypoactive sexual desire disorder (American Psychiatric Association, 2013; Flanagan & Peters,
2020).
Generally, allosexual individuals have a negative view of asexual individuals.
Researchers found that college students endorsed asexual individuals as the least likely sexual
orientation to possess positive traits and were the least likely sexual orientation to be viewed
favorably (MacInnis & Hodson, 2012). An example of a trait that asexual individuals were not
assigned was that of being in concordance with human nature. Asexual individuals were viewed
as less human than allosexual individuals because of their diminished sexual desire. In MacInnis
and Hodson’s (2012) study, Bastian and Haslam’s (2010) method of measuring trait-based
dehumanization was used. The means of positive (broadminded, conscientious, humble, polite,
thorough, active, curious, friendly, helpful, and fun-loving) and negative (disorganized, hard-
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 29
hearted, ignorant, rude, stingy, impatient, impulsive, jealous, nervous, and shy) traits were used.
Asexual individuals scored as the least human group of individuals compared to heterosexual,
homosexual [sic], and bisexual individuals. It is not uncommon for allosexual individuals to
view asexual individuals as having a deficit, going through a phase, or having a quality that can
be fixed (Carrigan, 2011; Chasin, 2015; Van Houdenhove et al., 2015).
Some transgender people also struggle with a profoundly negative social context because
they experience stigma and discrimination related to gender nonconformity (Bockting et al.,
2013). According to the 2011 National Transgender Discrimination Survey, 63% of transgender
individuals encountered a severe act of discrimination because of prejudice. Severe acts of
discrimination due to prejudice included job loss, eviction, sexual or physical violence,
incarceration, homelessness, denial of medical service, bullying, and loss of a romantic or filial
relationship (Grant et al., 2011). Among those who faced a severe act of discrimination, 23%
experienced three or more of these events and consequent financial insecurity or emotional
instability (Grant et al., 2011). The more recent 2015 U.S. Transgender Survey shows that many
TGNC individuals may face a dismal social environment; 46% of individuals described being
verbally harassed, and 9% conveyed that they were physically assaulted because of their gender
identity (James et al., 2016). In addition, 29% of the respondents stated that they live in poverty
compared to 12% of the overall population, which may be connected to employment
discrimination and provocation associated with gender identity (James et al., 2016). Other
research showed that as many as 56% of transgender people feel unsafe in public, and 60%
report experiencing physical abuse at some point in their lives (Kenagy & Bostwick 2005).
Being more likely to live in poverty and being more likely to experience verbal harassment are
connected to being more likely to feel unsafe. Gender-related discrimination also exists in other
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 30
areas of TGNC people’s lives, including healthcare and housing (Nuttbrock et al., 2010). The
interconnection between employment and health insurance is also related to employment
discrimination, loss of employment, and consequently, a higher likelihood of living in poverty.
A spate of anti-trans legislation has spread across the United States since 2021. At the
time of writing, five states had banned or limited participation in sports and the ability to receive
medical treatment for transgender youth (Crary, 2021). Few tangible repercussions have
materialized thus far for states that have passed anti-trans legislation. It is legal to discriminate
against TGNC people in housing and public accommodations in 27 states (and sexual minority
people in 26 states; Freedom for All Americans, n.d.). At the federal level, the situation is not
much better; the Equality Act would ban discrimination against gender and sexual minorities
nationwide, but its progress toward becoming law has stalled, and its prospects look bleak in the
currently polarized United States Senate (Lang, 2021). The difficulties TGNC people experience
may be due to negative attitudes among some cisgender people toward TGNC individuals. For
instance, research has shown that cisgender individuals may be more likely to believe that TGNC
individuals are abnormal, disordered, or even immoral (Ajzen & Fishbein, 2005; Parent & Silva,
2018; Winter et al., 2009; Worthen, 2016).
When considering individuals who are TGNC and asexual, the implications are clear.
Individuals holding both identities may be more prone to suffering double discrimination.
Individuals with intersectional identities can experience compounded discrimination at numerous
levels, including interpersonal (e.g., rejection by family), social (e.g., churches), and structural
(e.g., employment, policies; Williams et al., 2020). For instance, in Williams et al.’s (2020)
research, individuals who identified as both sexual and gender minorities were at a higher risk
for worse mental health due to heightened exposure to minority stress processes than individuals
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 31
who identified solely as a sexual minority person. This may also be the case specifically for
intersectional asexual TGNC individuals.
Psychological Distress in Asexual, TGNC, and Asexual TGNC Individuals
As previously mentioned, minority stress refers to the chronic stressors faced by
members of stigmatized minority groups, including sexual and gender minorities (Lefevor et al.,
2019; Meyer, 2003; Testa et al., 2015). Experiencing minority stressors alone does not cause
psychological distress; instead, it occurs through a mediation process. Psychological mediation
refers to how minority stressors can cause mental health issues by elevating risk factors such as
rumination (Hatzenbuehler, 2010). When external stressors are experienced, proximal stress via
processes such as internalization via rumination or isolation, can lead to mental health issues
(Sarno et al., 2020).
Only one study (McInroy et al., 2020) has examined minority stressors and mental health
outcomes in asexual individuals and compared them based on whether they were TGNC or
cisgender. No studies have tested these links with psychological moderators or protective factors
(e.g., resilience), which is why researchers have called attention to focusing on the relationships
between minority stressors, rumination, and psychological distress in asexual and asexual TGNC
individuals (Sarno et al., 2020; Timmins et al., 2020).
Asexual Psychological Distress
The limited available research on asexual adult mental health has shown that
psychopathology, such as alexithymia, was not higher among asexual people than among
allosexual people (Brotto et al., 2010). Instead, according to Brotto et al.’s quantitative analysis,
the most likely psychological difficulties were social withdrawal, anger problems, and suicidal
thinking. Researchers have found a higher incidence of anxiety, hostility, depression,
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 32
psychoticism, phobia-related anxiety, and suicidality among asexual people than among
allosexual people (Yule et al., 2013). Similarly, Carvalho et al. (2016) found that asexual people
reported higher levels of neuroticism, depression, phobic anxiety, and neuroticism, and lower
extroversion relative to allosexual people. These psychological characteristics may make
individuals vulnerable to emotional disturbances and mood dysphoria (Carvalho et al., 2016).
Isolation and its associated personality traits seem to be common themes in research that predict
psychological distress.
TGNC Psychological Distress
Psychological distress is widespread in the TGNC community (James et al., 2016). In the
largest survey of TGNC people conducted in the United States, 39% of TGNC people reported
experiencing psychological distress the month before taking the survey. Other studies have
confirmed that TGNC people are at a significantly higher risk of self-harm, suicide, substance
abuse, depression, and anxiety (Kenagy & Bostwick, 2005; Liu & Mustanski, 2012, Meyer et al.,
2017; Mustanski et al., 2010; Nemoto et al., 2004, 2011; Warren et al., 2016). This research
points to a theme similar to that of research on asexuality: TGNC people face heightened
disparities relative to LGB people. Higher psychological distress in TGNC people relative to
sexual minorities was observed in a recent large study on gender and sexual minority experiences
of depression and anxiety (Borgogna et al., 2018). Newcomb et al. (2020) found that TGNC
youth had worse mental health problems than their cisgender sexual minority peers due to
heightened psychosocial risk factors such as experiencing verbal harassment, disrespect, trauma,
victimization, and childhood sexual abuse associated with their minority gender identities.
According to minority stress theory, minority stressors (both proximal and distal) lead to
increased psychological distress in TGNC people, thereby resulting in disproportionate rates of
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 33
anxiety, depression, self-harm, suicidal ideation and attempts, and substance abuse relative to
cisgender people (Poquiz et al., 2021). Previous research indicates more frequent psychological
distress and depression diagnoses among TGNC versus cisgender individuals (Bockting et al.,
2013; Crissman et al., 2019; James et al., 2016; Meyer et al., 2017). A test of gender minority
stress theory found that nonaffirmation, rejection, and victimization were associated with
heightened suicidal ideation through TGNC people experiencing greater internalized
transnegativity and negative expectations (Testa et al., 2017). Psychological distress is not
universally experienced the same way in the TGNC community. Some people who identify as
TGNC experience more or less psychological distress than others within the TGNC community.
Research comparing differences is limited. The group differences are described in detail in the
following paragraphs.
Psychological Distress in Transgender Women. Psychological distress may be
relatively higher among TGW than among other individuals in the TGNC community. One study
found that TGW had the lowest psychological well-being across most variables they measured
(Warren et al., 2016). In that study, TGM fell between TGW and non-binary individuals in terms
of risk factors and outcomes (Warren et al., 2016). The findings of that study indicated that non-
binary individuals might be at lower risk of depression and anxiety than TGM and TGW
(Warren et al., 2016). However, other research have shown that TGW are at a lower risk of
suicide attempts (Brennan et al., 2017). Recent research has indicated that TGW and non-binary
AMAB individuals reported the worst health outcomes on multiple measures of psychological
distress, except for depression (Newcomb et al., 2020).
Psychological Distress in Transgender Men. Some studies have shown that TGM
report higher anxiety, suicidal ideation, self-harm, and sexual abuse than TGW (Arcelus et al.,
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 34
2016; Bouman et al., 2017; Holt et al., 2016; Richards, 2016). Rimes et al. (2019) found higher
rates of mental health problems among TGM than TGW. This may be attributable to the higher
rates of sexual abuse and domestic violence among AFAB individuals (Rimes et al., 2019;
Sterzing et al., 2019). Odds of poor physical and mental health were approximately two and a
half times higher in TGM than in TGW (Cicero et al., 2020). Odds for poor mental health days
were higher at about one and a half to two times higher than for TGM and gender non-binary
individuals. In one study on depression, non-binary AMAB youth and TGM had higher
depression scores than TGW and non-binary AFAB youth (Newcomb et al., 2020). Another
study also found that that TGM specifically had higher levels of mental illness (Millet et al.,
2017). Overall, it appears TGM have higher psychological distress than TGW and there may be
higher psychological distress among AMAB GNC individuals.
Psychological Distress in Gender Non-Conforming Individuals. GNC individuals
appear to have even higher levels of psychological distress than TGW and TGM. Cicero et al.
(2020) found that the odds of poor mental health were approximately two and a half times higher
in non-binary individuals than in TGW. More recent research has shown that GNC people may
be at a heightened risk of depression and anxiety relative to TGM and TGW (Crissman et al.,
2019; Thorne et al., 2019a). Additionally, non-binary individuals had the highest rates of some
adverse outcomes, such as traumatic experiences and suicidality (Newcomb et al., 2020). Non-
binary individuals experience more anxiety and depression as well as lower self-esteem than
either TGW or TGM (Thorne et al., 2019a). Similarly, GNC individuals have reported being
more stressed and hopeless than TGW (Veale et al., 2017). Another recent study showed that the
highest mental distress was among GNC individuals, closely followed by TGM, with TGW
experiencing the least mental distress (Crissman et al., 2019). The authors posited that biological
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 35
and socialization factors may be at play, which explains the similarly high mental distress among
cisgender women. Yet another study found that non-binary individuals fared worse on health
indicators (Burgwal et al., 2020). Despite mixed findings, current symptoms of serious
psychological distress are higher among GNC individuals than TGW or TGM, according to large
studies conducted in the United Kingdom and the United States (Government Equalities Office,
2018; James et al., 2016).
Asexual TGNC Psychological Distress
Research on the intersectional experience of asexuality and gender diversity has just
begun (Cuthbert, 2019). It is important to note that studies on the asexual community have
almost exclusively focused on cisgender participants (Sumerau et al., 2018). No studies
explicitly related to psychological dysfunction in asexual TGNC adults could be located. Yet,
researchers have noted that the interaction between heteronormativity and cisnormativity may
affect psychological well-being (Sumerau et al., 2018). Considering the probability that
psychotherapists will interact with TGNC clients who also identify as asexual (Rachlin, 2019), it
is crucial for researchers to continue to investigate this intersectional identity. Initial results with
TGNC asexual people indicate a particular vulnerability to adverse mental health outcomes
(McInroy et al., 2020).
Distal and Proximal Stressors for Asexual, TGNC, and Asexual TGNC Individuals
Figures 1 and 2 depict Meyer’s (2003) and Testa et al.’s (2015) minority stress theories,
respectively. These figures depict how stigma and discrimination can be experienced externally
by gender and sexual minorities as distal stressors or internalized by individuals as proximal
stressors. In gender minority stress theory, Hendricks and Testa (2012) related stigmatizing
experiences to minority stress and resultant morbidity in TGNC people. These experiences
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 36
include gender-based victimization, rejection, discrimination, and non-affirmation (Testa et al.,
2015). Minority stress works through external events, such as medical pathologization,
interpersonal discrimination, and societal stigma and through internal events like anticipatory
anxiety, identity concealment, and hypervigilance. The external events make TGNC people
vulnerable to stress and subsequent health problems (Bockting et al., 2013). External and internal
minority stress and its associated distress could lead to internalized transphobia developing in
many TGNC individuals (Hendricks & Testa, 2012). Figure 3 depicts Mink et al.’s (2014)
intersectional ecology model of sexual minority health, where an intersectional minority identity
interacts with sexual minority identity, affecting the minority stress process.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 37
Figure 3
Intersectional Ecology Model of Sexual Minority Health
Note. From “Stress, stigma, and sexual minority status: The intersectional ecology model of
LGBTQ health,” by M. D. Mink, L. L. Lindley, and A. A. Weinstein, 2014, Journal of Gay &
Lesbian Social Services, 26(4), p. 504
(https://doi.org/10.1080/10538720.2014.953660). Copyright 2014 by Taylor and Francis.
Reprinted with permission.
Minority stressors related to the asexual community may increase and have a
compounded effect when coupled with TGNC minority stress (Gamarel et al., 2014; Gupta,
2015; Rachlin, 2019). Recent research indicates that for emerging sexual and gender minority
individuals (e.g., pansexual, queer, and asexual individuals), proximal stressors, such as
rumination, may play an outsized role in levels of psychological distress (McInroy et al., 2020;
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 38
Timmins et al., 2020). Proximal stressors could significantly exacerbate psychological distress
after experiencing distal stressors such as prejudice events (Timmins et al., 2020).
Distal Stressors in Asexual Individuals
Asexual people struggle with many distal stressors, including interpersonal stigma and
discrimination from allosexual culture, scrutinization of asexual identity, and questions regarding
the normalcy of asexual identity (Kim, 2014). For example, allosexual culture may describe
asexuality as a fabrication, a superiority or inferiority complex, a form of immaturity, a type of
pathology, or an orientation that inevitably leads to loneliness and dissatisfactory interpersonal
relationships (Cerankowski & Milks, 2010; MacInnis & Hodson, 2012). In addition, it is often
argued in dominant culture that an asexual identity for men goes against the male sexual
imperative. For instance, in men, sexual desire is stereotyped as compulsory, and not being
interested in sex is subsequently considered evidence of a defect, lack of wholeness, or a sign of
being unhealthy (Przybylo, 2014). In women, asexuality is considered aberrant as it can be
interpreted as a sign of frigidity against men (Kim, 2014). All of these stressors are experienced
externally; the process is different when distal stressors are internalized as proximal stressors.
Proximal Stressors in Asexual Individuals
Although little is known about individual stigma in asexual individuals, the
internalization of negative beliefs related to their sexual orientation is likely due to findings
indicating elevated anxiety and depression among asexual identified adults and youth (Borgogna
et al., 2018; McInroy et al., 2020). This may be due to society’s largely negative views
concerning asexuality and people’s tendency to discriminate against asexual individuals.
McInroy et al. (2020) posited that proximal stressors might play a greater role in affecting the
psychological well-being of asexual youth and young adults than distal stressors. They suggested
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 39
that this may be because asexual individuals lack sexual attraction while existing in a highly
sexualized dominant culture.
McInroy et al. (2020) found that asexual youth and young adults had significantly higher
LGBTQIA-phobia, self-perceived stress, and poorer mental health than allosexual LGBTQIA
youth and young adults. Interestingly, asexual youth and young adults also were less at risk for
interpersonal or distal stressors than allosexual LGBTQIA individuals (McInroy et al., 2020).
This may be due to youth and young adults facing fewer distal stressors because of the
distinctive patterns of risks and challenges that may increase distal stressors with age (Dunlap,
2016; Herbenick et al., 2010; McInroy et al., 2020). Second, lower distal stressors among asexual
youth and young adults may be due to a higher ability to be perceived as allosexual in situations
in which asexuality may be stigmatized. A heightened ability to be perceived as allosexual and
the associated concealment behavior may be a coping strategy that helps avoid distal stressors.
However, research has shown that concealment behavior can also heighten proximal stressors in
sexual minority individuals, including asexual individuals (Mahon et al., 2020).
Other research has indicated that asexual individuals commonly experience isolation
because they feel excluded from LGBTQIA and heterosexual spaces (Dawson et al., 2018).
Dawson et al.’s (2018) research used a sample of asexual adults and found that experiencing
proximal stress, specifically isolation, was a common theme. Like distal stressors, research
suggests that proximal stressors, such as internalized negativity, isolation, and vigilance, tend to
be heightened among asexual individuals, and those with heightened proximal stressors could be
at risk of heightened psychological distress.
Distal Stressors in TGNC Individuals
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 40
Distal stressors can range from transphobic microaggressions to various other traumatic
events (e.g., harassment and violence), including interpersonal stigma and discrimination, which
are pervasive in the TGNC community (Namaste, 2000; Reicherzer et al., 2011). TGNC
individuals face higher stigma rates and discrimination than cisgender people, who identify as
lesbian, gay, bisexual, and queer (LGBQ), and they often face stigmatization within the
LGBTQIA community (Bauerband & Galupo, 2014; Kattari et al., 2016). For example, 25.1% of
cisgender LGBQ individuals reported having experienced workplace discrimination, whereas
50% of TGNC individuals reported workplace discrimination (Kattari et al., 2016). Similarly,
interpersonal discrimination is also prevalent; for instance, when needing to use the bathroom,
people who identify as TGNC have experienced microaggressions and violence from their
cisgender peers (Galupo et al., 2014; Sandil & Henise, 2017). Further, it is estimated that 10% of
TGNC people have a family member who was violent toward them before they came out as
TGNC and 8% of TGNC people have been ousted from their homes (James et al., 2016).
Overall, it appears that TGNC individuals can experience a high number of distal stressors.
The likelihood of discrimination and stigma may be related to the extent to which a
TGNC person can be perceived as not visibly TGNC. If gender nonconformity is visible and a
TGNC person is perceived as visibly TGNC, distal stressors may be more likely to occur
(Bockting et al., 2013; Grant et al., 2011; Sevelius, 2013). As many as 90% of people who
identify as TGNC report directly experiencing discrimination and prejudice at work, and many
people who identify as TGNC still do not have non-discrimination policies at their workplaces to
prevent discrimination (Grant et al., 2011; Human Rights Campaign, 2019).
Examples of structural stigma and discrimination include the fact that it is legal to fire or
evict those who identify as TGNC in 28 states. Furthermore, many states have considered
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 41
legislation to prevent people who identify as TGNC from using bathrooms concordant with their
gender identity (Sandil & Henise, 2017). Relatedly, poverty rates are significantly higher among
people who identify as TGNC than among the general population, and are partially explained by
the 15% unemployment rate among people who identify as TGNC (James et al., 2016).
Historically, discriminatory state-level laws and policies have significantly predicted poorer
mental health outcomes in TGNC individuals (Blosnich et al., 2016; Cicero et al., 2020;
Hatzenbuehler et al., 2010). This is due to the intertwined nature of employment, socioeconomic
status, mental health, and discrimination in the United States. TGNC people living in states with
employment discrimination protections may have a 26% decreased rate of mood disorders;
similarly, those with a lower socioeconomic position are 1.5–2 times more likely to have poor
health (Blosnich et al., 2016; Cicero et al., 2020).
People who identify as TGNC deal with significant stigma and disparagement from
cisgenderist medical culture. This cisgenderism manifests through clinician fixation with
transition and surgery; the exclusive focus on these experiences can feel objectifying for TGNC
people (Steinmetz, 2014). Another example of medical pathologization is that TGNC people
often experience denial of coverage and care. Denial of coverage for gender affirmative medical
interventions occurs due to the procedures being deemed “medically unnecessary” or “cosmetic”
by insurance companies (Khan, 2013). In addition to denial of coverage for services, some
clinicians may even outright deny TGNC people access to care; denial of care due to
discrimination may be as high as 20% because of unaccepting attitudes toward TGNC clients
(Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, 2009; Bockting
et al., 2004; James et al., 2016; Grant et al., 2011; Hendricks & Testa, 2012; Reicherzer et al.,
2011; Xavier et al., 2013). Stigmatizing and discriminatory experiences (distal stressors) are not
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 42
universally experienced in the same manner in the TGNC community. Some people who identify
as TGNC experience more stigma and discrimination than others within the TGNC community;
however, research comparing differences is limited. The group differences are described in detail
in the following paragraphs.
Distal Stressors in Transgender Women. According to some researchers, TGW may
experience a higher rate of distal stressors, specifically harassment and discrimination, than
TGM (Grant et al., 2011; Schilt, 2010). For instance, TGW reportedly experience much more
discrimination than TGM due to violating the systemic masculinity associated with their SAAB.
TGW may have more distal stressors because of the more rigid nature of gender roles for those
AMAB because they have less room to explore gender identity than TGM or those AFAB (De
Cuypere, 2016; Fassinger & Arseneau, 2007). Because individuals AFAB have less rigid gender
roles prescribed to them, they may experience fewer distal stressors. TGW appear to have a
higher level of distal stressors experienced than TGM individuals.
Distal Stressors in Transgender Men. No current research describes TGM as
experiencing more distal stressors than TGW. However, some studies indicate that TGM and
TGW experience more discrimination than non-binary individuals (Poquiz et al., 2021). Poquiz
et al. explained that this could be due to social transition and gender expression differences.
More distal stressors are experienced for TGM and TGW than non-binary individuals because of
more visible transition and gender expression discordant with the SAAB. This research is mixed;
while TGM certainly experience distal stressors, some research has shown that these experiences
occur in lower amounts for TGW and non-binary individuals (Poquiz et al., 2021).
Distal Stressors in Gender Non-Conforming Individuals. More recent research
indicates that GNC individuals experience more stigma and discrimination or distal stressors
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 43
than TGW and TGM (Lefevor et al., 2019; Matsuno et al., 2017). Some evidence suggests that
individuals experience stigma and discrimination based on their identity more frequently than
TGW and TGM (Matsuno et al., 2017). Relative to TGM, TGW, and cisgender individuals, GNC
individuals experience more harassment, sexual abuse, and traumatic events (Lefevor et al.,
2019). Many cisgender people already struggle to accept TGW and TGM. Cisgender individuals
may struggle even more to accept GNC individuals who fall outside the gender binary.
Consequently, GNC individuals may face unique stigmatizing complications with no clear
resolution, such as gendered restrooms, pronouns, and titles in documentation (Richards, 2016;
Stocks, 2015; Wiseman & Davidson, 2012). GNC individuals tend to have a non-heterosexual
orientation compared to TGW and TGM, which may exacerbate the social stigma they
experience (Harrison et al., 2012). In addition to the stigma and discrimination GNC individuals
experience, some researchers argue that there is continued invisibility in the media, advertising,
films, and literature; this invisibility makes resolving problems with binary choices, such as
gendered restrooms and pronouns, more difficult, which may result in greater stress (Lefevor et
al., 2019).
The frequency of discrimination and stigma may depend on the SAAB of non-binary
individuals. Some studies have indicated that GNC AMAB individuals report greater threats of
identity-related victimization and physical violence due to gender identity or expression
(Chavanduka et al., 2020; Rimes et al., 2019; Sterzing et al., 2019). Non-binary AMAB
individuals are likely to experience more identity-related victimization and violence due to
diverging from their AMAB identities in favor of incorporating and accepting more feminine or
non-binary identities (Chavanduka et al., 2020). Overall, GNC individuals appear to experience
the highest level of distal stressors based on the current literature.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 44
Proximal Stressors in TGNC Individuals
Proximal stressors in TGNC individuals include expectations of rejection, internalized
transnegativity, and identity concealment (Bockting et al., 2013). Proximal stressors can result
from TGNC individuals more frequently experiencing distal stressors, which can be internalized,
resulting in the avoidance and concealment of stigma and diminished self-efficacy regarding the
ability to cope with stigmatizing experiences for people who identify as TGNC (Hendricks &
Testa, 2012; White Hughto et al., 2015). People who identify as TGNC are often hypervigilant
regarding distal stressors, such as the potential for stigmatizing experiences, regularly perceiving
stigma, and anxiously reacting to stigmatizing experiences. These experiences often lead to
increased proximal minority stress, including internalized transnegativity, identity concealment,
and expectations of rejection (Testa et al., 2015). Heightened proximal stressors can cause
anxiety and depression through psychological mediation and increased proximal stressors can
lead to poor mental health and reduced well-being (Borgogna et al., 2018; Hatzenbuehler et al.,
2010; Testa et al., 2015; Williams et al., 2020).
Proximal Stressors in Transgender Women. TGW may have higher proximal stressors
than transgender men and GNC individuals (Brennan et al., 2017). Higher proximal stressors for
TGW may be due to their heightened rumination and hypervigilance relative to other TGNC
individuals, which is associated with more frequent experiences of distal stressors. Connected to
more frequent experiences of distal stressors is the lower ability of TGW, in particular, to be
perceived by others as not TGNC (Poquiz et al., 2021). Poquiz et al. found that TGW had more
negative future expectations than TGM. They believe that this may be due to participants being
acutely attuned to the adverse health outcomes experienced disproportionately by TGW.
Therefore, proximal stressors could be heightened in TGW relative to other TGNC individuals.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 45
Proximal Stressors in Transgender Men. Regarding other proximal stressors
(specifically, identity concealment), TGM may have more identity concealment than non-binary
individuals because of their more effortless ability to be read as their gender and conceal their
assigned sex without medical intervention (Poquiz et al., 2021). While the ability to be perceived
as not visibly TGNC may yield benefits, it could also contribute to heightened proximal stress
(e.g., identity uncertainty or lack of centrality). Sexual and gender minority research indicates
that higher levels of identity uncertainty and lower levels of identity centrality are associated
with lower self-esteem and psychological well-being, respectively (Morandini et al., 2015;
Shramko et al., 2018). Therefore, because some TGM can be read more readily as their gender
and conceal their gender identity, they may not identify with the overall TGNC community.
Thus, TGM may potentially miss some of the resilience factors associated with community
connectedness. TGW and non-binary individuals may be less able to conceal their gender
identity than those who are TGM, which is why they may experience less concealment proximal
stress (Poquiz et al., 2021). While identity concealment, may be higher in TGM, it appears that
other proximal stressors may be lower relative to other TGNC individuals, which could be
related to their lower levels of psychological distress.
Proximal Stressors in Gender Non-Conforming Individuals. Research indicates that
GNC individuals’ higher distal stressors (such as invalidation and erasure) may cause them to
experience proximal stressors, such as hypervigilance and internalized transphobia more
frequently and intensely than TGW and TGM (Lefevor et al., 2019). This may lead to fewer
social interactions, greater social isolation, and hypervigilance (Hendricks & Testa, 2012; Wyss,
2004). In one study, non-binary individuals had heightened negative future expectations relative
to TGM and TGW. This finding was attributed in part to acute awareness and rumination
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 46
regarding denial of care by healthcare providers who were less informed about options for non-
binary medical transition (Poquiz et al., 2021). Essentially, proximal stressors, such as
rumination and anxiety, may be heightened in this subset of the overall TGNC community
because of the higher distal stressors they face. Proximal stressors in GNC individuals may be
the highest in the TGNC community.
Distal Stressors in Asexual TGNC Individuals
Distal stressors may be experienced because of both gender identity and sexual
orientation among intersectional asexual TGNC individuals. Interpersonal stigma exists in this
community; because of hegemonic masculinity, men are expected to initiate sex, always be
interested in sex, and be easily aroused and satisfied by sex (Gupta, 2018; Przybylo, 2014). In
contrast, social scripting calls for women to be seen as people who make themselves sexually
attractive to men and who are prone to participate in sex in the context of sexual activation
through a significant relationship (Gupta, 2018). If they are not sexually active, their
unavailability to men is considered disruptive.
Distal stressors can be experienced interpersonally and structurally among intersectional
asexual TGNC individuals. Stigmatizing experiences, including verbal abuse and disparaging
comments toward asexual people who break gendered sexual scripts, are not uncommon (Vares,
2017). Holding an intersectional identity as a TGNC individual and an asexual individual likely
creates a stronger combined distal stressor experience for asexual TGNC people. Structural
stigma also exists for asexual TGNC people; most depictions of asexual people do not portray
them as having TGNC identities (Sumerau et al., 2018). The study of asexuality has largely
mirrored other research areas with a nearly exclusive focus on cisgender populations. This
tendency makes asexual TGNC people, who already feel invisible, more invisible to researchers
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 47
and clinicians (Sumerau et al., 2018). Due to this invisibility, some asexual TGNC clients may
not bring up their asexual orientation with clinicians. This is due to fear of pathologization; some
may fear that an asexual identity would conflict with their ability to receive hormone therapy or
surgical intervention (Chasin, 2011). While a few studies have been conducted on gender
differences within the allosexual TGNC community, research that describes gender differences
among individuals holding an intersectional identity could not be located.
Proximal Stressors in Asexual TGNC Individuals
In a recent study of asexual youth and young adults, high levels of internalized
(individual) stigma and shame were found among asexual TGNC participants (McInroy et al.,
2020). An interactive effect was found for those who were asexual and TGNC, relative to those
who were allosexual and TGNC. Heightened internalized stigma and feeling that something is
wrong with them among asexual TGNC individuals make sense because of the heavily gendered
social scripts they are violating with both their sexual and gender identities (Cuthbert, 2019).
Asexual TGNC qualitative research participants were very aware of how others sexualized their
bodies, and some purposely created a more gender-neutral expression to avoid objectification
(Cuthbert, 2019).
Resilience in Asexual, TGNC, and Asexual TGNC Individuals
When experiencing minority stress, TGNC people can develop pride in their gender
identity and promote hope for the future through the recognition and navigation of that identity
and cohesiveness with other minority members (Hendricks & Testa, 2012; Singh & McKleroy,
2010). TGNC individuals may experience elevated isolation and shame prior to coming out
because of gender nonconformity with the SAAB (Bockting et al., 2013; Hendricks & Testa,
2012). Coming out involves acknowledging identity and risking the loss of interpersonal
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 48
connections due to societal stigma; a potential benefit after coming out includes TGNC people
achieving self-acceptance (Bockting & Coleman, 2016). After achieving self-acceptance,
exploration takes place, which involves learning about TGNC identities, establishing connections
with the TGNC community, and investigating gender expression. This is critical because
intimate connections with the TGNC community can facilitate other benefits such as identity
pride. Minority stress is still a factor due to issues such as societal stigma and medical
pathologization. However, TGNC people with greater identity pride are more resilient in
managing minority stressors and buffering levels of psychological distress (Breslow et al., 2015;
Bockting et al., 2013; Budge et al., 2013; Graham et al., 2014; Riggle et al., 2011). Robbins et al.
(2015) discovered initial findings that support a similar process for asexual individuals in
developing identity pride and centrality through community connectedness as a resilience factor.
Asexual Resilience
Minority stress theory includes resilience as an essential part of that theory; resilience
factors can buffer the effects of stressors (Meyer, 2015). Initially, resilience was identified as a
protective framework for sexual minority men, and greater resilience was correlated with better
self-reported mental health (Herrick et al., 2013). It is now recognized that other sexual
minorities also experience resilience as a protective framework that may result in better self-
reported mental health (Meyer, 2003; Meyer, 2015). While the concept of resilience has not been
researched explicitly in the asexual community, prior research has confirmed that various forms
of anti-asexual discrimination can increase stress in asexual individuals (Gazzola & Morrison,
2012). If asexual individuals experience minority stress, resilience factors may help buffer stress.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 49
Researchers have identified traits that may indicate resilience among asexual people. One
such trait is the asexual community’s development and use of language that celebrates
differences (i.e., cultivating an aptitude to describe asexuality and embrace it as an identity).
Other ways of displaying resilience include developing new types of non-sexual relationships
that facilitate social support and de-emphasize the importance of sexuality in life (Gupta, 2018;
Robbins et al., 2015). Those who have not heard of the term “asexuality” but identified as
asexual might experience higher isolation, distress, and confusion than individuals who belong to
a community of asexual identified people (Brotto et al., 2010; Brotto & Yule, 2009). Similarly, a
systematic literature review identified the importance of validating asexual identity through
engagement with asexual communities (Jones et al., 2017).
Community support may buffer the experience of minority stress by acting as a source of
resilience for asexual individuals, as it does for other sexual minority individuals (Williams et
al., 2020). Because of the diminished probability of engaging in at least some health-risk
behaviors (e.g., less substance misuse and less suicidal behavior), further research regarding
navigating threats to well-being is needed to determine whether this is related to community
resilience (McInroy, 2019; McInroy et al., 2020). In one study, a fully mediated relationship was
found between community belongingness and the relationship between the strength of TGNC
identity and well-being (Barr et al., 2016). Thus, when asexual individuals discovered asexual
communities and the existence of asexuality, Van Houdenhove et al. (2015) found that they
could make sense of and accept their identities.
Individual resilience is illustrated by the concept of mastery and indicates the personal
agency or qualities that sexual minority people possess to help them cope with stress (Meyer,
2015). Individual resilience may be bolstered by community resilience or group-based coping,
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 50
such as being part of the internet-based Asexuality Visibility and Education Network (AVEN;
MacNeela & Murphy, 2014). Collective self-esteem may act as a buffer; for instance, the
Asexual Microaggressions Scale scores are significantly negatively correlated with Collective
Self-Esteem Scale scores (Foster, 2017). It seems both individual and community resilience may
be useful resilience attributes for asexual individuals.
TGNC Resilience
Phenomenological research has identified five themes of resilience in TGNC individuals:
(a) evolving definition of self (and gender identity); (b) embracing self-worth; (c) awareness of
oppression (which aids in distinguishing trans-positive from trans-negative messages); (d)
connection to a supportive community; and (e) cultivation of hope for the future (Singh et al.,
2011). Exploratory factor analysis in a separate study indicated different types of resilience
among TGNC people, including cognitive coping techniques such as positive reframing and
letting go and behavioral techniques such as seeking social support (Budge et al., 2013).
Resilience could function as a protective factor for TGNC individuals by providing assets and
resources to help moderate the negative effects of minority stress associated with cisnormativity
(Fergus & Zimmerman, 2005; Woodford et al., 2018). Seeking social support seems to be a
critical coping strategy for identity-related stress and helps reduce less adaptive coping skills
(e.g., diminished use of avoidant coping; Budge et al., 2013).
Research has also shown that TGNC resilience is connected to having a supportive
community and is negatively associated with gender-related stigma and psychological distress
(Fredriksen-Goldsen et al., 2013; Gonzalez et al., 2012; Trujillo et al., 2016). Support that
buffers the relationship between stigma and distress can include family and peer support
(Bockting et al., 2013). In this research study, only peer support significantly moderated the
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 51
relationship between enacted stigma and mental health. Other studies have shown a significant
moderating effect of family support. For instance, the association between discrimination and
anxiety was found to be significant with low and moderate family support but not at high levels
of family support (Scandurra et al., 2017). Research shows that peer support buffers the
relationship between stigma and distress (Bockting et al., 2013; Nuttbrock et al., 2014, Pflum et
al., 2015). Perceived relational support reduces distress by increasing a sense of belongingness
and affecting individual-based resilience (e.g., increasing self-esteem and self-efficacy), thereby
increasing emotional stability and reducing the risk of suicide (Edwards et al., 2019; Trujillo et
al., 2016). Thus, community-based resilience promoted individual-based resilience among
TGNC people. Resilience factors are not universally experienced the same way by all members
of the TGNC community. Some people who identify as TGNC experience more or fewer
resilience factors than others within the TGNC community; research comparing differences is
limited.
Resilience in Transgender Women. Researchers have indicated that identity pride may
be greater among TGW and GNC individuals than TGM, due to greater representation of TGW
and GNC people than TGM in the media (Capuzza & Spencer, 2016). In addition, TGW
typically have a stronger connection to and involvement with the LGBTQIA community than
TGM due to being more visibly gender non-conforming and experiencing more minority
stressors (Poquiz et al., 2021). With increased involvement in the LGBTQIA community, there
may be a “normative” effect regarding distal stressors and psychological difficulties (Warren et
al., 2016). This normalization effect may help facilitate resilience.
Resilience in Transgender Men. TGM may have less access to resilience factors than
other TGNC individuals. Some studies have shown that TGM may have lower self-esteem than
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 52
TGW and GNC individuals (Warren et al., 2016). The researchers hypothesized that this may
have been due to feeling less connected to the LGBTQIA community and TGM feeling as if their
participation in the community was temporary until they could be perceived as not visibly TGNC
(Factor & Rothblum, 2008; Warren et al., 2016). This may reduce exposure to resilience factors
such as community belongingness (Barr et al., 2016). Lower access to resilience factors may
indicate lower resilience among TGM than among other communities within the TGNC
community.
Resilience in Gender Non-Conforming Individuals. GNC people may have difficulty
finding community in either the LGBTQIA community or the trans community; finding
community is critical to buffering internalized transphobia and promoting resilience (Testa et al.,
2015). GNC individuals, particularly those with intersectional identities, may feel like they do
not belong to the LGBTQIA community, depriving them of stress-buffering experiences that
TGM and TGW may have (Factor & Rothblum, 2008; Matsuno et al., 2017; Rankin & Beemyn,
2012). Among TGNC individuals, GNC individuals also seem to receive the lowest amount of
support from family and friends (Aparicio-García et al., 2018; Bradford & Catalpa, 2019). Yet,
even though GNC individuals receive less support from family and friends, they have nearly
identical self-esteem and social support to cisgender LGB people (Barr et al., 2016; Factor &
Rothblum, 2008; Warren et al., 2016). This may be because other studies point to a stronger
connection and involvement with the LGBTQIA community (Capuzza & Spencer, 2016; Poquiz
et al., 2021).
There may be differential effects on GNC resilience based on SAAB. Non-binary AFAB
individuals experience higher rates of feeling unique in their gender identity or expression, which
may be a source of resilience (Chavanduka et al., 2020; Newcomb et al., 2020). The pressures of
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 53
heteronormativity and hegemonic masculinity may explain this, and non-binary AFAB
individuals may feel a sense of pride because they do not assume a male identity (Chavanduka et
al., 2020). Pride is hypothesized to be felt because these individuals are acutely aware of
hegemonic masculinity's toxicity and feel pride in diverting from claiming that.
The research appears to be mixed regarding GNC individuals’ resilience. Other studies
have shown that non-binary individuals may be at risk of lower self-esteem (Thorne et al.,
2019a). Limited research indicates that GNC individuals may have the lowest levels of gender-
related family and social support, which may result in lower resilience, lower ability to buffer
distal/proximal stressors, and higher levels of psychological distress (Budge et al., 2013; Budge
et al., 2014; Fuller & Riggs, 2018; Factor & Rothblum, 2008; Koken et al. 2009; Riggs et al.,
2015). Overall, GNC individuals may have the lowest resilience within the TGNC community.
Asexual TGNC Resilience
Previous research on sexual and gender minorities, including those who are asexual and
TGNC, indicated that resilience is significantly associated with belonging to a community with
robust connections to others and having affirmative role models (Brotto & Yule, 2009; Brotto et
al., 2010; Fredriksen-Goldsen et al., 2013; Gonzalez et al., 2012; Gupta, 2018; Riggle et al.,
2008; Riggle et al., 2011; Rostosky et al., 2010; Trujillo et al., 2016). Because community
resilience is particularly salient for each of those minority identities, research and practice should
focus on opportunities to increase community resilience for intersectional identities such as those
who are asexual TGNC. Studies regarding other intersectional identities, such as TGNC people
of color, show social support conferred resilience, and it may be a crucial factor for those
communities (Singh & McKleroy, 2010; White, 2014). Thus, although asexual TGNC
individuals who experience multiple stressors (such as combined sexual orientation and gender
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 54
identity stigma) could be limited in their level of individual resilience, there could also be an
opportunity to promote resilience through the facilitation of community belongingness and
support.
Summary and Present Study
Asexual individuals struggle with high levels of distal and proximal stressors
(Cerankowski & Milks, 2010; Kim, 2014; MacInnis & Hodson, 2012). The asexual community
displays resilience by embracing a language within a community that honors their differences
and developing new types of non-sexual relationships in asexual communities (Gupta, 2018;
Jones et al., 2017). This collective cultivation of self-esteem may help buffer the experience of
minority stressors (Foster, 2017; Williams et al., 2020). The limited research available suggests a
higher level of psychological distress in the asexual community (Brotto et al., 2010; Carvalho et
al., 2016).
TGNC individuals also struggle with a high level of structural and social stigma and
prejudice (Bockting et al., 2013; Galupo et al., 2014; James et al., 2016; Sandil & Henise, 2017).
Resilience may buffer some minority stressors that TGNC people experience because of
cisgenderism (Fergus & Zimmerman, 2005; Woodford et al., 2018). This happens by cultivating
family, social, and individual resilience (Singh et al., 2011). Resilience may help overcome some
of the challenges associated with structural and social stigma and discrimination (Bariola et al.,
2015). The TGNC community experiences frequent and intense minority stressors without easy
access to stress buffers, resulting in disproportionate psychological distress (Bockting et al.,
2013; Crissman et al., 2019; James et al., 2016; Meyer et al., 2017). Prior research, especially
research related to intersectional identities regarding psychological well-being, resilience, and
minority stress levels, has used multiple regression as an analysis strategy (Everett et al., 2019;
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 55
Shangani et al., 2020). Previous studies have also found a moderation or combined effect
between predictor variables, such as resilience and experienced stigma, affecting the strength of
an outcome, such as minority stress in sexual and gender minority participants (Bockting et al.,
2013; Figueroa & Zoccola, 2015; Woodford et al., 2018).
While a relatively broad overview of asexual and TGNC communities is presented in this
literature review, research on the intersectional experience of asexual TGNC individuals is
limited. Fassinger and Arseneau (2007) contended that psychologists should be invited to assume
advocacy roles to educate others about communities’ unique needs under the LGBTQIA
umbrella. This points to the need to study minority stress and its relationship with factors such as
resilience and psychological distress in intersectional communities.
Based on this literature review, it is reasonable to assume that asexual TGNC people may
have heightened minority stress and uniquely limited access to support. Consequently, they may
have limited resilience and self-esteem to buffer the negative impact of internal and external
minority stress. This could adversely affect the mental health of this intersectional community
(Williams et al., 2020). Also to be considered are differences within the TGNC community,
which have only recently occurred in the field of gender minority research (Stanton et al., 2021).
Thus, the questions this study seeks to answer are as follows:
1. Do proximal (vigilance and isolation), distal (harassment & discrimination, and
victimization), and gender expression minority stress predict psychological distress
among asexual TGNC individuals?
H1a: Vigilance will be positively associated with psychological distress.
H1b: Isolation will be positively associated with psychological distress.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 56
H1c: Harassment and discrimination will be positively associated with psychological
distress.
H1d: Victimization will be positively associated with psychological distress.
H1e: Gender expression minority stress will be positively associated with psychological
distress.
2. Does resilience moderate the relationship between psychological distress and proximal
(vigilance and isolation), distal (harassment & discrimination, and victimization), and
gender expression minority stress among asexual TGNC individuals?
H2a: Vigilance is expected to be positively related to psychological distress at all levels of
resilience; this relation is expected to be weaker at high levels of resilience and stronger at
low levels of resilience.
H2b: Isolation is expected to be positively related to psychological distress at all levels of
resilience; this relation is expected to be weaker at high levels of resilience and stronger at
low levels of resilience.
H2c: Harassment and discrimination is expected to be positively related to psychological
distress at all levels of resilience; this relation is expected to be weaker at high levels of
resilience and stronger at low levels of resilience.
H2d: Victimization is expected to be positively related to psychological distress at all levels
of resilience; this relation is expected to be weaker at high levels of resilience and stronger at
low levels of resilience.
H2e: Gender expression minority stress is expected to be positively related to distress at all
levels of resilience; this relation is expected to be weaker at high levels of resilience and
stronger at low levels of resilience.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 57
3. Does resilience significantly differ in relation to gender identity among asexual TGNC
individuals?
H3a: There is expected to be a significant difference in resilience in relation to gender
identity among asexual TGW and GNC individuals. TGW are expected to have significantly
higher resilience when compared to GNC individuals.
H3b: There is expected to be a significant difference in resilience in relation to gender
identity among TGM and GNC individuals. GNC individuals are expected to have
significantly higher resilience when compared to TGM.
4. Do proximal (vigilance and isolation), distal (harassment & discrimination and
victimization), and gender expression minority stress significantly differ in relation to
gender identity among asexual TGNC individuals?
H4a: There is expected to be a significant difference in vigilance minority stress among
asexual TGW and GNC individuals. GNC individuals are expected to have significantly
higher vigilance when compared to TGW.
H4b: There is expected to be a significant difference in vigilance minority stress among
asexual TGW and TGM. TGW are expected to have significantly higher vigilance when
compared to TGM.
H4c: There is expected to be a significant difference in isolation minority stress among
asexual TGW and GNC individuals. GNC individuals are expected to have significantly
higher isolation when compared to TGW.
H4d: There is expected to be a significant difference in isolation minority stress among
asexual TGW and TGM. TGW are expected to have significantly higher isolation when
compared to TGM.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 58
H4e: There is expected to be a significant difference in harassment and discrimination
minority stress among asexual TGW and GNC individuals. GNC individuals are expected to
have significantly higher harassment and discrimination when compared to TGW.
H4f: There is expected to be a significant difference in harassment and discrimination
minority stress among asexual TGW and TGM. TGW are expected to have significantly
higher harassment and discrimination when compared to TGM.
H4g: There is expected to be a significant difference in victimization minority stress among
asexual TGW and GNC individuals. GNC individuals are expected to have significantly
higher victimization when compared to TGW.
H4h: There is expected to be a significant difference in victimization minority stress among
asexual TGW and TGM. TGW are expected to have significantly higher victimization when
compared to TGM.
H4i: There is expected to be a significant difference in gender expression minority stress
among asexual TGW and GNC individuals. GNC individuals are expected to have
significantly higher gender expression minority stress when compared to TGW.
H4j: There is expected to be a significant difference in gender expression minority stress
among asexual TGW and TGM. TGW are expected to have significantly higher gender
expression minority stress when compared to TGM.
5. Does psychological distress significantly differ in relation to gender identity among
asexual TGNC individuals?
H5a: There is expected to be a significant difference in psychological distress in relation to
gender identity among asexual TGW and GNC individuals. GNC individuals are expected to
have significantly higher psychological distress when compared to TGW.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 59
H5b: There is expected to be a significant difference in psychological distress in relation to
gender identity among asexual TGM and TGW. TGM are expected to have significantly
higher psychological distress when compared to TGW.
6. Does resilience moderate the relationship between proximal (vigilance and isolation),
distal (harassment & discrimination and victimization), and gender expression minority
stress, gender identity, and psychological distress among asexual TGNC individuals?
H6a: GNC individuals are expected to have significantly higher psychological distress than
TGW when they have high levels of vigilance and low levels of resilience.
H6b: TGM are expected to have significantly higher psychological distress than TGW when
they have high levels of vigilance and low levels of resilience.
H6c: GNC individuals are expected to have significantly higher psychological distress than
TGW when they have high levels of isolation and low levels of resilience.
H6d: TGM are expected to have significantly higher psychological distress than TGW when
they have high levels of isolation and low levels of resilience.
H6e: GNC individuals are expected to have significantly higher psychological distress than
TGW when they have high levels of harassment and discrimination and low levels of
resilience.
H6f: TGM are expected to have significantly higher psychological distress than TGW when
they have high levels of harassment and discrimination and low levels of resilience.
H6g: GNC individuals are expected to have significantly higher psychological distress than
TGW when they have high levels of victimization and low levels of resilience.
H6h: TGM are expected to have significantly higher psychological distress than TGW when
they have high levels of victimization and low levels of resilience.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 60
H6i: GNC individuals are expected to have significantly higher psychological distress than
TGW when they have high levels of gender expression minority stress and low levels of
resilience.
H6j: TGM are expected to have significantly higher psychological distress than TGW when
they have high levels of gender expression minority stress and low levels of resilience.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 61
Chapter III – Research Model, Methods, and Procedures
In this study, a quantitative approach using a correlational design was used. I used a
cross-sectional survey sample to test specific hypotheses, including whether significant
differences in psychological distress existed depending on the level of minority stress
experienced (gender expression minority stress, proximal or distal minority stress) among
asexual TGNC participants. Additionally, I tested how resilience moderates the relationship
between psychological distress and minority stressors, and explored whether resilience
significantly differs between gender identity groups. I also tested for significant differences
between gender identity groups in psychological distress and the three types of minority
stressors. Finally, I assessed whether resilience moderates the relationship between minority
stressors, gender identity, and psychological distress. This chapter reviews participant
characteristics, rationale for the research model and design, and measures and surveys used.
Methodological Design
Correlational design using quantitative research is a methodological archetype based on
positivist tradition (Kazdin, 2017). It includes concepts and practices such as using theory,
hypothesis testing, operational definitions, careful control of subject matter, isolation of the
variables of interest in a study, quantification of constructs, and statistical analysis of data
(Kazdin, 2017). The present study is considered cross-sectional because it made comparisons
using valid and reliable self-reported surveys between groups at a given point in time (Kazdin,
2017). Cross-sectional research may increase rival explanations of research findings by capturing
only data at one snapshot in time (Hoyt et al., 2008). Longitudinal studies can address this
limitation by making comparisons over an extended period; however, this approach often
involves comparisons over several years (Field, 2017; Kazdin, 2017). Furthermore, because of
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 62
the sensitive nature of sexual and gender minority research, previous research highlights the
importance of anonymity associated with recording internet-based survey responses at one point
in time (Woodford et al., 2018). For these reasons, online surveys were administered. Although a
probability sample survey rather than a convenience sample survey would have been ideal,
researchers have noted the difficulty of obtaining sufficiently large sample sizes of asexual and
TGNC participants without using convenience samples (Brotto & Yule, 2009; Henderson et al.,
2019).
Participants
A total of 300 participants met the inclusion criteria and completed the survey between
October 3, 2021, and October 24, 2021. Of those who participated, 48 were TGM (16.2%), 51
were TGW (17.2%), and 198 were GNC (66.7%). Participants ranged from 18 to 70 years old (M
= 26.27, SD = 7.86). Two-hundred and thirty participants (77.4%) identified as White, 15 (5.1%)
identified as Hispanic, Latino, or Spanish origin, 14 (4.7%) identified as Black or African
American, 10 (3.4%) identified as Asian, four (1.3%) identified as American Indian or Alaska
Native, two (0.7%) identified as Middle Eastern or North African, and 22 (7.4%) identified as
another race or ethnicity. One-hundred and fifty-three participants (51.5%) had incomes of less
than $25,000, 40 (13.5%) had incomes of $25,000–$34,999, 37 (12.5%) had incomes of
$35,000–$49,999, 33 (11.1%) had incomes of $50,000– $74,999, 11 (3.7%) had incomes of
$75,000–$99,999, seven (2.4%) had incomes of $100,000–$149,999, and five (1.7%) had
incomes of $150,000 or more. Six participants (2.0%) indicated an education level of some high
school, 57 (19.2%) indicated an education level of high school, 18 (6.1%) indicated an education
level of associate’s degree/trade school, 103 (34.7%) indicated an education level of some
college, 74 (24.9%) indicated an education level of bachelor’s degree, 34 (11.4%) indicated an
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 63
education level of master’s degree, and four (1.3%) indicated an education level of a doctoral
degree. Fifty-three participants (17.8%) had a feminine gender expression, 61 (20.5%) had a
masculine gender expression, 92 (31.0%) had an androgynous gender expression, 36 (12.1%)
had a genderqueer/gender non-conforming gender expression, 29 (9.8%) had a gender fluid
gender expression, and 25 (8.4%) reported another gender expression not listed. Twenty-five
participants (8.4%) reported a homoromantic orientation, six (2.0%) reported a heteroromantic
orientation, 121 (40.7%) reported an aromantic orientation, 36 (12.1%) reported a biromantic
orientation, 54 (18.2%) reported a panromantic orientation, and 50 (16.8%) reported a romantic
orientation not listed. Most participants (68.0%) met Yule et al.’s (2015) cutoff score for the
Asexual Identification Scale (AIS).
To participate, individuals had to (a) be 18 years of age or older, (b) self-identify as
asexual, (c) self-identify as TGNC, (d) read English proficiently, and (e) be residents of the
United States. Because of the unique sexual culture of America, which emphasizes a sexual
imperative and sexual shame, the inclusion of individuals in other countries may have obscured
the data (Yule et al., 2013). Participants were excluded from the study if they did not meet
inclusion criteria.
Sampling Procedures
The Michigan School of Psychology Institutional Review Board reviewed and approved
the study materials and procedures (Protocol #210901). Participants were recruited from email
listservs and online platforms (e.g., Facebook, Reddit, AVEN forums) for asexual and TGNC
communities using a recruitment flyer (Appendix A), linked to the electronic web-based survey
housed on Qualtrics. The recruitment posts included essential information (e.g., the purpose of
the study, who could participate, a statement that participation was voluntary, and the IRB
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 64
approval number). Potential participants were able to view this before beginning the survey.
Because of the sensitive nature of this study, a link to mental health resources for sexual and
gender minorities was included in the recruitment post for potential participants, and
participation in the survey was not required to access resource information. The participants who
consented to the study received the same set of resources upon completing the survey.
Upon accessing the online survey, participants were provided with informed consent
information (Appendix B). The agreement described the purpose of the study, potential risks
associated with involvement in the research, and procedures for maintaining confidentiality, and
participants had to check a box indicating their consent. Qualtrics provides IP addresses, which
were used to identify false and duplicate responses to be stripped from the working dataset
before analysis to protect participants’ privacy. Additionally, to protect their confidentiality,
participants were not asked for personal identifying information beyond that requested in the
consent form and demographics questionnaire. Participants who confirmed their understanding
of the informed consent and met the inclusion criteria in the subsequent inclusion screener
(Appendix C) were directed to the next page of the survey. The modified versions of the
standardized surveys (Kessler Psychological Distress Scale [K10], Protective Factors for
Resilience Scale [PFRS], Daily Heterosexist Experiences Questionnaire [DHEQ], and Asexual
Identification Scale) were randomized in Qualtrics to account for order effects (Bishop, 2008).
Before completion, a demographics questionnaire about participant race/ethnicity, age, gender
expression, romantic orientation, level of education, and income level was administered as the
last survey. The demographics questionnaire was presented at the end of the survey to prevent
stereotype threat or biasing of the participants’ answers (Fernandez et al., 2016). The
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 65
demographics questionnaire helped assess potential covariates and the generalizability of the
sample. The total number of questions from all the instruments, including demographics
questions, was 93. Permissions (Appendices D-G) were obtained from the primary researchers
for the use and adaptation of the standardized scales. The survey posed minimal risk to the
participants; however, some questions about minority stress-related topics could have caused
mild discomfort. With this in mind, participants were given a list of resources for crisis
counseling and mental health support for asexual and TGNC individuals on a debriefing page
(Appendix H) at the end of the survey, were reminded of their anonymity, and were provided
with contact information in case they had questions after completing the survey.
Measures
Asexual Identification Scale
Yule et al. (2015) developed the Asexual Identification Scale to assess asexual identity.
The AIS consists of 12 items that reflect one dimension (traits of asexuality). An example item is
“I lack interest in sexual activity.” Each item is rated on a 5-point Likert scale. Higher scores
suggest experiences more characteristic of people who identify as asexual. A total score is used
with a cutoff score of 40, with scores above 40 capturing 93% of self-identified asexual
participants and scores below the cutoff capturing 95% of self-identified allosexual participants.
The AIS included in the present study had good reliability with the study sample (M = 42.97, SD
= 6.93; α = .74).
Yule et al. (2015) reported the validity of AIS scores as supported by exploratory factor
analysis, showing that the final 12 items (of the original 111) loaded strongly and meaningfully
onto a single factor. Known-groups validity was demonstrated with a sample of 716 sexual and
164 asexual participants; an independent samples t-test showed that scores on the AIS-12
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 66
differed significantly between the groups (p < .001). Convergent validity was demonstrated with
respective moderate and weak correlations with Spector et al.’s (1996) Sexual Desire Inventory
(SDI) subscales Dyadic and Solitary (r = -.57, -.19). Discriminant validity was shown with a
non-significant correlation with Bernstein et al.’s (1994) Childhood Trauma Questionnaire
(CTQ), which was used because of the idea that negative sexual experiences may be construed as
indicative of asexuality.
The Asexual Identification Scale (AIS) was used for post-hoc validation of asexual
identity during data analysis. Because heterogeneity within the asexual community exists and
competing definitions for asexuality complicate research on this community, current researchers
recommend against allowing self-identification and argue for the operationalization of identity
(Van Houdenhove et al., 2017). Prause and Graham (2007) similarly cautioned against Bogaert’s
(2004) research model that included a single self-identification question about asexuality, which
has questionable validity. They criticized the lack of measures of desire, attraction, and
arousability and cautioned that the lack of operationalization might hinder the collection of
representative samples. Therefore, the use of Yule et al.’s (2015) Asexuality Identification Scale
is recommended for researching this population. Yule and other researchers have used this
questionnaire in numerous studies, capturing a large amount of the variance (Brotto et al., 2015;
Yule et al., 2016, 2017). The Asexuality Identification Scale is a 12-question scale with a 5-point
Likert scale that is valid and reliable, and helps differentiate asexual people from allosexual
individuals. The questions span topics including sexual disgust, avoidance, attraction, and
interest. A cutoff score greater than or equal to 40 for participants delineates who is considered
asexual. While this scale operationalizes asexuality and may improve research, the lack of
allowing participants to self-identify moves in a direction opposite to that of the American
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 67
Psychological Association and the field of psychology (American Psychological Association,
2013, 2021). Therefore, this scale was used after the survey to validate self-identification, rather
than as a strict inclusion measure.
Kessler et al. (2003) Psychological Distress Scale
Kessler et al. (2003) developed the Kessler Psychological Distress Scale to assess non-
specific psychological distress among adults. An example item includes “During the last 30 days,
how often did you feel tired out for no good reason?” The K10 consists of 10 items reflecting
how frequently individuals have experienced symptoms of psychological distress in the past 30
days. Each item was rated on a 5-point Likert scale assessing frequency ranging from 1 (none of
the time) to 5 (all of the time). Higher scores indicate experiences of people with more
psychological distress and diagnosable mental illnesses. A total score under 20 indicates
individuals who are likely to be well, between 20 and 24 indicates individuals who have a mild
mental disorder, between 25 and 29 reflects people who have a moderate mental disorder, and
between 30 and 50 indicates individuals who have a severe mental disorder (Andrews & Slade,
2001). Cronbach’s alpha for the full-scale K10 was excellent and ranged from α = .92 to .93 in
initial studies (Kessler et al., 2002). Researchers assessing psychological distress in American
and Australian transgender individuals reported values of α = .93 and .94, respectively (Bariola
et al., 2015; Tan et al., 2020). The K10 included in the present study had acceptable reliability
with the study sample (M = 27.89, SD = 6.93; α = .75).
Kessler et al. (2002) reported validity of the K10 supported by exploratory factor
analysis, showing that the final 10 items (of the original 45) loaded strongly and meaningfully as
a unidimensional factor. Good validity was observed in the initial validation. Kessler et al.
(2002) ensured construct validity by selecting questions from a comprehensive variety of
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 68
prevailing psychological distress questionnaires and evaluating questions using an expert panel.
Predictive validity has been found with adequate prediction of affective disorders from the fourth
edition of the Diagnostic and Statistical Manual using Sheehan et al.’s (1998) Mini-International
Neuropsychiatric Interview (MINI; Hides et al., 2007). Cronbach’s alpha for the present study
was .75.
Protective Factors for Resilience Scale
Harms et al. (2017) developed the Protective Factors for Resilience Scale to assess
resilience in adults. The PFRS includes 15 items that reflect three dimensions: personal resources
(five items), peer social resources (five items), and family social resources (five items). It is
especially salient that the PFRS includes social and family resilience, as these types of resilience
have been identified as particularly important to the LGBTQIA community (Kwon, 2013). An
example item includes “I can achieve what I set out to do” (Harms et al., 2017). Each item is
rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). A
composite score is then used. Higher subscale scores indicate higher resources on each subscale,
and higher scores indicate greater overall resilience (e.g., adaptive problem-focused coping,
adaptive re-appraisal of problems, and social support). The full-scale Cronbach’s alpha for the
PFRS among Australian and North American individuals was excellent at .93 (Harms et al.,
2017). Researchers subsequently found values of α = .96 among Australian cancer survivors, and
α = .81 and α = .85 among the Spanish general population and Spanish chronic illness patients
(Harms et al., 2018; León et al., 2020). The reliability of the subscales ranged from .77 to .90
among Spanish patients with chronic illness and from .78 to .90 among the Spanish general
population individuals (León et al., 2020). The PFRS included in the present study had good
reliability with the study sample (M = 4.51, SD = .95; α = .84).
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 69
Harms et al. (2017) established the validity of the PFRS supported by exploratory factor
analysis, showing that the final 15 items (of the original 40) loaded strongly onto the three
factors. They also established adequate construct validity. Positive correlations were found
between the overall PFRS score and coping style, self-esteem, and life satisfaction (Harms et al.,
2017). Convergent validity was determined using the Brief COPE. Subsequent research by León
et al. (2020) found evidence of adequate convergent validity through positive correlations with
Scheier et al.’s (1994) Life Orientation Test-Revised (LOT-R) Optimism subscale, Ryff's (1989)
Psychological Well-Being Scale (PWB), and Smith et al.’s (2008) Brief Resilience Scale (BRS;
correlation coefficients ranged from .23 to .68). A negative correlation was found (r = -.33) for
the LOT-R Pessimism subscale.
Daily Heterosexist Experiences Questionnaire
Balsam et al. (2013) developed the Daily Heterosexist Experiences Questionnaire to
assess minority stress in LGBT adults. The DHEQ includes 50 items reflecting nine dimensions:
vigilance (six items), harassment and discrimination (six items), gender expression minority
stress (six items), parenting (six items), victimization (four items), family of origin (six items),
vicarious trauma (six items), isolation (four items), and HIV/AIDS (six items). An example item
begins with the question, “How much has this problem distressed or bothered you during the past
12 months?” and includes “difficulty finding LGBT friends.” Each item is rated on a 6-point
Likert scale ranging from 0 (did not happen/not applicable to me) to 5 (it happened, and it
bothered me extremely). Higher scores indicate higher minority stress. The scores on the nine
subscales had internal reliabilities of α = .86, .85, .86, .83, .87, .79, .82, .76, and .79, respectively.
The internal reliability of the DHEQ full-scale was α = .92. Staples et al. (2017), in a study
focused exclusively on transgender individuals, reported internal reliability for the Harassment &
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 70
Discrimination and Victimization subscales of α = .76 and .87, respectively. The DHEQ
subscales used in the present study had acceptable reliability with the study sample for (a)
harassment & discrimination (M = 1.01, SD = 1.11; α = .79), (b) victimization (M = .22, SD =
.74; α = .75), (c) vigilance (M = 1.66, SD = 1.07; α = .76), and (d) gender expression minority
stress (M = 1.69, SD = 1.12; α = .72). The isolation subscale used in the present study had
questionable reliability with the study sample (M = 1.95, SD = 1.15; α = .65).
Balsam et al. (2013) described the validity of the DHEQ supported by exploratory factor
analysis, showing that the final 50 items (of an original 80) loaded strongly and meaningfully
onto the nine factors. They found acceptable construct validity. There were moderate correlations
with assessments of psychological distress (e.g., depression, anxiety, posttraumatic stress
disorder, and perceived stress). These were measured using (a) Andresen et al.’s (1994) 10-item
Center for Epidemiological Studies Depression Scale, (b) Kroenke et al.’s (2007) Patient Health
Questionnaire-Anxiety, (c) Weathers et al.’s (1993) PTSD Checklist Civilian Version, and (d)
Cohen et al.’s (1983) Perceived Stress Scale-Short Form (PSS-SF). Similarly, concurrent validity
was supported. The DHEQ scores correlated moderately with the two general LGB
discrimination queries from Mohr and Fassinger’s (2000) Outness Inventory. One of these items
assessed the interference of homophobia in living a rewarding and productive life. The other
item was related to how different people think their lives would be if they did not have to deal
with the challenges associated with LGBT identity.
Demographic Questionnaire
Demographic variables were collected for three reasons: (a) as an a-priori
inclusion/exclusion measure for the rest of the online measures; (b) to collect relevant data that
might explain differences found in response patterns and use the information in the model to
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 71
control for covariates (e.g., age cohort, socioeconomic status); and (c) to collect descriptive data
about this sample, about whom little has been written about in the research literature. The
questionnaire (Appendix I) included racial/ethnic self-identification response items.
Fernandez et al.’s (2016) approach was used as a guide to create categories for
race/ethnicity. The categories include American Indian or Alaska Native; Hispanic, Latino, or
Spanish origin; White; Asian; Middle Eastern or North African; Black or African American;
Native Hawaiian or Other Pacific Islander; and “Another Race or Ethnicity not Listed Above.”
Research indicates different experiences of psychological distress among TGNC people based on
race/ethnicity (Koken et al., 2009; Meyer, 2010; Singh & McKleroy, 2010; White, 2014). In
addition to race/ethnicity, respondents were asked about their age. Studies indicate that younger
TGNC individuals face unique difficulties compared with older TGNC individuals (Arcelus et
al., 2016; Rimes et al., 2019). In addition, asexual attitudes may have shifted due to increased
awareness over the past two decades since the creation of AVEN in 2001, and young people
increasingly identifying as asexual; consequently, age could predict psychological distress
(Flore, 2014; The Trevor Project, 2020). Participants were also asked about their gender identity
(male, transgender male/transgender man, female, transgender female/transgender woman,
genderqueer/gender non-conforming/non-binary, or a different identity [please state]). Badgett et
al. (2014) of the Williams Institute identified this as a best practice method for asking about
gender identity. Additionally, participants were asked about gender expression because research
indicates that psychological distress may differ depending on gender expression (Balsam et al.,
2013; Chavanduka et al., 2020; Newcomb et al., 2020; Poquiz et al., 2021; Rimes et al., 2019;
Sterzing et al., 2019). Participants were also asked about their romantic orientation in the adapted
AIS to account for the fact that some individuals might identify themselves as heteroromantic,
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 72
homoromantic, aromantic, or another romantic orientation (Chasin, 2011). Because asexual
experiences of psychological distress can differ based on romantic orientation, it was important
to control for this potential covariate (Sasayama et al., 2022). Finally, options were provided so
that participants could report their highest level of education and annual income; research
indicates that these variables can act as buffers against psychological distress among TGNC
individuals (Breslow et al., 2015). Five demographic variables were assessed as covariates: race,
age, gender expression, romantic orientation, education level, and social class. A sixth
demographic area (gender identity) was analyzed as a predictor.
Analytic Strategy
Raw survey data were uploaded to IBM SPSS (Version 28.0) for Mac. One of the main
analyses used for the first, second, and sixth sets of hypotheses in the present study was multiple
regression. Although the research in this study could have used several univariate tests,
multivariate analyses were more appropriate because multivariate analysis reduces error and
could better answer the research questions; measures are conceptually related, and the research
was looking at interactive effects among measures (Kazdin, 2017). Multiple regression is
particularly well suited to research seeking to control variables and find a moderation effect
among variables (Kazdin, 2017).
Multiple regression is used to build a model with several predictors (IVs) that are
continuous and predict a continuous dependent variable (DV) (Field, 2017). The study used
multiple regression to explore relationships between the dependent variable in this study
(psychological distress) and several independent variables (the proximal and distal minority
stressors assessed and gender expression minority stress, resilience, and gender identity of
participants). Predictors need to be selected based on “sound theoretical rationale or well-
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 73
conducted past research that has demonstrated their importance” (Field, 2017, p. 295). For
example, based on the literature, it was reasonable that minority stress (both gender-based and
based on sexual orientation) would affect the degree of psychological distress people experience.
Based on the literature, adding the variable of resilience affected the level of minority stress
(Meyer, 2003; Testa et al., 2015). Hierarchical regression was used because the order predictors
are entered into the model are selected based on past work (Hoyt et al., 2008). Hierarchical linear
regression allows for the examination of incremental validity by assessing the contribution of
predictors beyond previously entered predictors (Field, 2017). To test the theory that a
moderation relationship exists between resilience, the proximal and distal stressors assessed,
gender expression minority stress, and psychological distress (Hypothesis 2), scores on each of
those scales were added first to the regression model to control for their collective influence on
psychological distress. Interactions were added second to account for their contributions beyond
those of other variables. This was done to test the theory that a moderation relationship exists
between resilience, the proximal and distal stressors assessed, gender expression minority stress,
gender identity, and psychological distress (Hypothesis 6). A similar process was employed by
Wei et al. (2008) to control for variables in the regression analysis before examining the
interactions between resilience factors, discrimination, and depressive symptoms in Asian sexual
minority individuals.
Other main analyses included analysis of variance (ANOVA) for the third and fifth set of
hypotheses and Kruskal-Wallis H tests for the fourth sets of hypotheses to assess group
comparisons. ANOVA is used with a continuous dependent variable and an independent
categorical variable to assess comparisons of sample means (Caldwell, 2013). In this analysis,
observations were independent. While several t-tests could have been used, ANOVA analyses
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 74
were more appropriate because they reduce Type I error risk. Multivariate analysis of variance
(MANOVA) is used with multiple groups, which offers a way to look at interactions between
outcome variables, and it allows the researcher to contrast sample groups for differences. When
its assumptions are not satisfied, non-parametric tests such as Kruskal-Wallis H tests are used
(Field, 2017). To examine group differences within sexual and gender minority communities
ANOVA and Kruskal-Wallis H tests were used. Prior research has done the same, rather than
using identity as a predictor variable (Chavanduka et al., 2020; McConnell et al., 2018; Poquiz et
al., 2021).
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 75
Chapter IV – Presentation of Findings
In this chapter, analytic methods are described, statistical assumptions are reviewed, and
results are reported. Specifically, three types of analysis were conducted to test the six research
questions. Research question 1 assessed the predictive relationship between gender expression
minority stress, proximal (vigilance and isolation), and distal minority stress (harassment &
discrimination and victimization), and psychological distress using multiple linear regression.
Research questions 2 and 6 used hierarchical linear regression. Research question 2 assessed
whether resilience significantly moderates the relationship between psychological distress and
proximal, and distal minority stressors and gender expression minority stress. Research question
6 assessed whether resilience moderates the relationship between proximal and distal, minority
stressors, gender expression minority stress, gender identity, and psychological distress.
Research questions 3 and 5 used ANOVA. Research question 3 assessed for differences in
resilience by gender identity subgroups, and research question 5 tested for overall differences in
psychological distress by gender identity subgroups. Finally, research question 4 used Kruskal-
Wallis tests and tested for overall differences in both proximal and distal minority stressors and
gender expression minority stress by gender identity subgroups.
Missing Data
Data from 300 participants were collected through an online survey. Missing data were
evaluated by examining the completion rate of each questionnaire and filtering them from the
dataset. Descriptive data were reviewed for variables with missing values. Across the entire
dataset, only 1% were missing data across psychological distress, resilience, and minority stress
questionnaires. Of that 1%, the percentage of missing data was 53.12%. The initial plan for
missing data was imputation by replacing the missing values for variables with the mean value.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 76
However, over 10% of the data were missing for participants who were missing data (n = 3), and
when this occurs, mean imputation may not be appropriate (Bennett, 2001). Therefore, the data
from these participants was excluded from the study.
Statistical Assumptions
Linear regression requires that three specific assumptions be met before running the
analysis. First, the criterion variable must be continuous. Psychological distress was measured as
a continuous variable using the K10. Second, there must be two or more continuous or
categorical predictors. Measures to assess vigilance, isolation, harassment & discrimination,
victimization, and gender expression minority stress met this assumption. Each of these self-
report subscales uses continuous interval values to assess the severity level, thereby meeting
assumption two.
Before further analysis, a linear relationship must exist between the predictor and the
criterion variables. The linear regression assumptions of normality and linearity are assessed
using Q-Q Plots. The fourth assumption requires that residuals must be uncorrelated; a Shapiro-
Wilk test, with a p-value > .05, is needed to meet this assumption. After reviewing the Shapiro-
Wilk test, the residuals were found to be uncorrelated, with a p-value > .05, therefore meeting
this assumption. Next, there must be a test of homoscedasticity, in that residuals must have equal
variances, checked using a residual scatterplot to determine the distribution, and there is no
pattern; thus, the data appear to be homoscedastic. If the residuals have equal variances, the
scatterplot looks random. Upon reviewing the scatterplot, this assumption was met. Assumption
six requires the residual errors to be normally distributed, and that there be a lack of similarity
among the data points. This is reviewed by (a) checking the standard errors of skewness and
kurtosis and confirming that they did not deviate from a ratio of less than -2 or greater than 2
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 77
(see Table 1) and (b) verifying that the clusters of data points represent a bell curve checked
using a histogram. The final assumption that must be met states that there must be no extreme
multicollinearity among variables; this is assessed by finding acceptable tolerance and variance
inflation factor (VIF) levels. VIF levels ranged from 1.05 to 2.11, and tolerance levels ranged
from .47 to .77, with VIF levels above 10 and tolerance scores below .2 indicating
multicollinearity (Kim, 2019). All assumptions for the linear regression were met.
Table 1
Descriptive Statistics
Variable
M
SD
Skewness (SE)
Kurtosis (SE)
Psychological distress
27.89
6.93
-0.65 (0.14)
-0.14 (0.28)
Resilience
4.51
0.95
-0.18 (0.14)
-0.52 (0.28)
Harassment & discrimination
1.01
1.11
1.28 (0.14)
1.24 (0.28)
Victimization
0.22
0.74
3.94 (0.14)
16.22 (0.28)
Isolation
1.95
1.15
0.39 (0.14)
-0.38 (0.28)
Vigilance
1.66
1.07
0.85 (0.14)
0.54 (0.28)
Gender expression minority stress
1.69
1.10
0.67 (0.14)
-0.04 (0.28)
The first assumption evaluated for ANOVA is the normal distribution of each category
for the IV on the DV. There is a need to show evidence of approximate normality, and the
Shapiro-Wilk test was used to determine if this was violated. The Shapiro-Wilk test was non-
significant, indicating that the assumption of normality was not violated and that there are no
normality issues. The other assumption to check for ANOVA was the homogeneity of variances.
This was evaluated using Levene’s test of homogeneity of variances. Here there was also a non-
significant result, indicating that there were no issues. All assumptions for the ANOVA were
met.
A MANOVA tests whether an independent categorical variable explains a statistically
significant amount of variance in the dependent variable by comparing the weighted linear
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 78
combination to determine whether it differs by separate groups of independent variables.
MANOVA, rather than a series of ANOVA tests, reduces the chance of Type II error. Several
parametric assumptions must be met to conduct a MANOVA. First, the independent variable
(IV) must be categorical, and the dependent variables (DV) must be continuous. The IV in this
study was gender identity (trans-man, trans-woman, or gender non-conforming), resulting in one
categorical variable with three levels. This research study used multiple DVs, consisting of
several subscales assessing both proximal and distal minority stressors and gender expression
minority stress. Each of the self-report subscales was continuous, thereby meeting this
assumption. Next, there must be independence of observations, meaning that participants were
not used in a repeated measure or within-group design, which for this study was not the case. In
this study, survey participants were separated into three groups based on their gender identity:
TGM, TGW, and GNC individuals. The analysis was conducted using data from 48 TGM, 51
TGW, and 198 GNC individuals.
Next, the assumptions of MANOVA were checked. The assessment of a linear
relationship measured by Q-Q Plots that should give the appearance of a line was confirmed. In
addition, there must be no multicollinearity; this was assessed using Pearson’s bivariate
correlations. After reviewing the Pearson’s bivariate correlations, all dependent variables have a
low to moderate correlation with each other, and no multicollinearity was identified. A linear
relationship was determined between isolation, vigilance, harassment & discrimination,
victimization, and gender expression minority stress scores within gender non-conforming
individuals, trans women, and trans men, as assessed by the Q-Q Plot. Levene’s test was non-
significant and indicated that it met the assumption of homogeneity of variances, F(2, 267) = .12,
p = .89. Box’s M Test of Equality of Covariance Matrices had a non-significant (p > .001)
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 79
finding in this study indicating that the assumption of homogeneity of variance-covariance
matrices was met. MANOVA assumptions also require that there are no univariate or
multivariate outliers. To identify univariate outliers, the labeling methods described by
Tabachnick and Fidell (2019) were used; no participant data were more than 3.29 SD from the
mean; therefore, there were not any univariate outliers. Multivariate outliers were identified
using Mahalanobis distance (MD), the distance between two points in multivariate space. MD is
met if every variable has a power of .01 or more (Mahalanobis, 1936; Weiner et al., 2012). The
results indicate that there were no multivariate outliers. Multivariate normality was tested using
the Shapiro-Wilk test of normality, which indicates that the data were not normally distributed
due to a significant p-value. Because of the issue identified with normality in assumptions
testing, data transformations are attempted to correct for normality as outlined by Lee (2020), but
this was unsuccessful in correcting normality. As such, during the analysis phase, the Kruskal-
Wallis H tests were used instead of MANOVA, as per Finch’s (2005) suggestion to use the
Kruskal-Wallis test as a nonparametric test when assumptions are violated for MANOVA.
Preliminary Analyses
As a preliminary analysis, Pearson’s Bivariate Correlation was conducted to examine
whether multicollinearity existed between variables before testing whether there was a predictive
relationship between variables. Psychological distress positively correlated with several predictor
variables (see Table 2), with correlations between psychological distress and vigilance (r = .38, p
≤ .01), isolation (r = .32, p ≤ .01), harassment & discrimination (r = .32, p ≤ .01), victimization
(r = .21, p ≤ .01), and gender expression minority stress (r = .37, p ≤ .01), and a significant
negative correlation between psychological distress and resilience (r = .480, p ≤ .01). Among the
predictor variables, significant negative correlations exist between resilience and harassment &
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 80
discrimination (r = -.25, p ≤ .01), resilience and victimization (r = -.19, p ≤ .01), resilience and
isolation (r = -.26, p ≤ .01), resilience and vigilance (r = -.19, p ≤ .01), resilience and gender
expression minority stress (r = -.31, p ≤ .01), and harassment & discrimination and being gender
non-conforming (r = -.11, p ≤ .05). Significant positive correlations were found between
harassment & discrimination and victimization (r = .47, p ≤ .01), harassment & discrimination
and isolation (r = .40, p ≤ .01), harassment & discrimination and vigilance (r = .49, p ≤ .01),
harassment & discrimination and gender expression minority stress (r = .59, p ≤ .01),
victimization and isolation (r = .16, p ≤ .01), victimization and vigilance (r = .28, p ≤ .01),
victimization and gender expression minority stress (r = .27, p ≤ .01), isolation and vigilance (r
= .40, p ≤ .01), isolation and gender expression minority stress (r = .53, p ≤ .01), vigilance and
gender expression minority stress (r = .50, p ≤ .01), and resilience and being gender non-
conforming (r = .11, p ≤ .05).
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 81
Table 2
Pearson Bivariate Correlations Among Variables
Variable
M
SD
1
2
3
4
5
6
7
8
9
10
11
1. AIS
42.97
6.93
-
2. R
4.51
0.95
-.08
-
3. H
1.01
1.11
.11
-.25**
-
4. V
0.22
0.74
.00
-.19**
.47**
-
5. I
1.95
1.15
.01
-.26**
.40**
.16**
-
6. Vg
1.66
1.07
.02
-.19**
.49**
.28**
.40**
-
7. GMS
1.69
1.10
-.04
-.31**
.59**
.27**
.53**
.50**
-
8. PD
27.89
6.93
.04
-.48**
.32**
.21**
.32**
.38**
.37**
-
9. Age
26.37
7.92
-.06
.08
.04
.13*
.06
.01
.08
-.22**
-
10. Ed
4.06
1.36
-.15*
.17**
.03
-.01
.05
.06
.16**
-.17**
.34**
-
11. SES
2.16
5.36
-.01
.17**
-.12*
-.08
.14*
-.01
-.02
-.21**
.25**
.20**
-
Note. Total n = 297, AIS = asexual identification scale score; R = resilience scale score; H = harassment &
discrimination scale score; V = victimization scale score; I = isolation scale score; Vg = vigilance scale score; GMS
= Gender expression minority stress; PD = psychological distress scale score; Ed = education; SES =
Socioeconomic status.
*p ≤ .05. **p ≤ .01.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 82
Main Analyses
Research Question 1
The intent of research question 1 was to investigate whether the proximal, and distal
minority stressors assessed and gender expression minority stress predict psychological distress.
To test research question 1, a multiple regression was conducted with the predictor variables and
controlling for covariates (age, education, race, gender expression, romantic orientation, and
SES; see Table 3). The results indicate that the model is significant and a good fit, with 30% of
the variance accounted for by minority stress beyond the covariates, R2 = .30, F(11, 258) =
10.21, p < .001, f2 = .43. Specifically, vigilance is a significant predictor of psychological
distress, such that an increase in vigilance shows a .22 SD increase in psychological distress (β =
0.22, p < .001). Gender expression minority stress is a significant predictor of psychological
distress, such that an increase in gender expression minority stress shows a .24 SD increase in
psychological distress (β = 0.24, p < .001). Isolation (β = 0.11, p = .09), harassment &
discrimination (β = -0.02, p = .79), and victimization (β = 0.08, p = .17) do not significantly
predict psychological distress.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 83
Table 3
Regressions of Associations Between Minority Stressors and Psychological Distress
Variable
Psychological distress
B
SE
β
Intercept
29.52
1.89
Vigilance
1.31
0.37
0.22***
Isolation
0.59
0.35
0.11
Harassment & discrimination
-0.11
0.41
-0.02
Victimization
0.71
0.51
0.08
Gender expression minority stress
1.39
0.42
0.24***
Age
-0.13
0.05
-0.17**
Race
0.15
0.23
0.03
Gender expression
-.012
0.24
-0.03
Romantic orientation
-0.14
0.24
-0.03
Education
-0.61
0.26
-0.13*
SES
-0.51
0.23
-0.12*
R2
.30
Note. N = 258. Race was dummy coded such that 0 indicates White and 1 indicates other races.
There were not enough people in each subcategory to code separately. Romantic orientation is
dummy coded such that 0 indicates aromantic and 1 indicates other romantic orientations.
There were not enough people in each subcategory to code separately.
*p< .05. **p<.01. ***p< .001.
Research Question 2
Research question 2 explored whether there is a moderation effect of resilience on the
relationship between psychological distress and both proximal and distal minority stressors
assessed and gender expression minority stress. A hierarchical regression model is used to test
research question 2 (see Table 4). Hierarchical linear regression was conducted with the first-
order predictor variables included in the first step, controlling for covariates (age, education,
race, gender expression, romantic orientation, and SES). Interaction terms were included in the
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 84
second step. Interaction terms were created by multiplying the composites of each predictor by
the composite score of resilience. The results indicate that the model is significant and a good fit,
with approximately 40% of the variance accounted for by the relationship between minority
stressors and resilience beyond the covariates, R2 = .399, F(17, 252) = 9.84, p < .001, f2 = .67.
Resilience is a significant predictor of psychological distress, such that an increase in resilience
shows a -.33 SD decrease in psychological distress (β = -0.33, p = .01). Vigilance (β = 0.36, p =
.22), isolation (β = 0.19, p = .53), harassment & discrimination (β = -0.14, p = .69), victimization
(β = 0.01, p = .97), and gender expression minority stress (β = -0.01, p = .97) did not
significantly predict psychological distress. Furthermore, vigilance x resilience (β = -0.16, p=
.58), isolation x resilience (β = -0.13, p = .66), harassment & discrimination x resilience (β =
0.14, p = .66), victimization x resilience (β = 0.03, p = .92), and gender expression minority
stress x resilience (β = 0.14, p = .64) did not significantly predict psychological distress.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 85
Table 4
Hierarchical Multiple Regression Results for Psychological Distress Without Gender Identity
Variable
B
95% CI for B
SE B
β
R2
ΔR2
LL
UL
Step 1
Intercept
38.84
34.32
43.36
2.29
.397
.397
Vigilance
1.21
0.53
1.89
0.35
0.20**
Isolation
0.34
-0.30
0.99
0.33
0.06
H&D
0.01
-0.75
0.77
0.39
0.00
Victimization
0.28
-0.67
1.23
0.48
0.03
GEMS
0.81
0.02
1.60
0.40
0.14*
Resilience
-2.32
-3.04
-1.60
0.37
-0.35***
Age
-0.13
-0.21
-0.04
0.22
-0.16**
Race
0.23
-0.19
0.66
0.22
0.05
Gender expression
-0.13
-0.57
0.30
0.22
-0.03
RO
0.07
-0.37
0.51
0.22
0.02
Education
-0.31
-0.80
0.18
0.25
-0.07
SES
-0.31
-0.73
0.12
0.22
-0.08
Step 2
Intercept
38.23
30.10
46.37
4.13
.399
.002
Vigilance
2.12
-1.24
5.48
1.71
0.36
Isolation
1.03
-2.17
4.24
1.63
0.19
H&D
-0.77
-4.56
3.01
1.92
-0.14
Victimization
0.11
-4.65
4.86
2.42
0.01
GEMS
-0.07
-3.66
3.52
1.82
-0.01
Resilience
-2.20
-3.80
-0.60
0.81
-0.33**
Age
-0.13
-0.22
-0.04
0.05
-0.17**
Race
0.25
-0.18
0.69
0.22
0.06
Gender expression
-0.11
-0.56
0.33
0.23
-0.03
RO
0.09
-0.37
0.54
0.23
0.02
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 86
Variable
B
95% CI for B
SE B
β
R2
ΔR2
LL
UL
Education
-0.33
-0.82
0.17
0.25
-0.07
SES
-0.29
-0.72
0.15
0.22
-0.07
Vigilance x Resilience
0.19
-0.94
0.53
0.44
0.14
Isolation x Resilience
0.06
-0.86
0.55
0.60
0.03
H&D x Resilience
0.19
-0.67
1.05
0.40
0.14
Victimization x Resilience
2.12
-1.13
1.25
1.71
0.36
GEMS x Resilience
1.03
-0.60
0.99
1.63
0.19
Note. CI = confidence interval; GEMS = gender expression minority stress; H&D = harassment and discrimination; LL
= lower limit; RO = romantic orientation; UL = upper limit. Race is dummy coded such that 0 indicates White and 1
indicates other races. There were not enough people in each subcategory to code separately. Romantic orientation is
dummy coded such that 0 indicated aromantic and 1 indicated other romantic orientations. There were not enough
people in each subcategory to code separately.
*p< .05. **p<.01. ***p< .001.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 87
Research Question 3
The aim of this research question was to assess differences to determine whether
resilience differs among TGM, TGW, and GNC individuals. One-way analysis of variance
(ANOVA) was conducted (see Table 5). The results demonstrate that resilience, F(2, 261) =
2.08, p = 0.37, η2 = .02, does not significantly differ based on gender identity.
Table 5
Means, Standard Deviations, and One-Way Analysis of Variance in Resilience and
Psychological Distress
Measure
TGM
TGW
GNC
F (2, 261)
η2
M
SD
M
SD
M
SD
Resilience
4.28
.12
4.44
.15
4.59
.07
2.08
.02
Psychological
distress
29.23
.79
26.92
.87
27.81
.46
0.37
.01
Research Question 4
The purpose of research question 4 was to assess differences in the proximal, and distal
minority stressors assessed and gender expression minority stress among TGW, TGM, and GNC
individuals. A series of Kruskal-Wallis H tests were performed to determine the extent of this
pattern. As evidenced by this test, there are differences in harassment & discrimination based on
gender identity, χ2(2) = 7.27, p = .026, η2 = .02. Subsequently, pairwise comparisons were
performed using Dunn’s (1964) procedure, as outlined by Dinno (2015). A Bonferroni correction
was made by dividing α = .05 by the eight comparisons at the p < .006 level. The post-hoc
analysis revealed no significant differences in harassment & discrimination scores between TGM
(mean rank = 171.06) and other gender identities, TGW (mean rank = 164.17) and other gender
identities, or GNC individuals (mean rank = 139.74) and other gender identities. In addition, the
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 88
Kruskal-Wallis H tests reveal that there were no significant differences in victimization χ2(2) =
2.61, p = .271, η2 = .002, isolation χ2(2) = 0.58, p = .749, η2 = .005, vigilance χ2(2) = 3.69, p =
.158, η2 = .006, or gender expression minority stress χ2 (2) = 2.63, p = .269, η2 = .002 based on
gender identity.
Research Question 5
Research question 5 assessed whether psychological distress differs among TGM, TGW,
and GNC individuals. One-way ANOVA was conducted (see Table 5). The results demonstrate
that psychological distress, F(2, 261) = 1.00, p = 0.37, η2 = .01, does not significantly differ
based on gender identity.
Research Question 6
The aim of research question 6 was to explore whether there was a moderation effect of
resilience on the relationship between both proximal and distal minority stressors assessed,
gender expression minority stress, gender identity, and psychological distress. Gender identity is
dummy coded such that TGM (0 = TGW, GNC, 1 = TGM), TGW (0 = TGM, GNC, 1 = TGW),
and GNC (0 = TGM, TGW, 1 = GNC). GNC is not included in the models that make all
comparisons against GNC individuals. A hierarchical regression model was used to test research
question 6 (see Table 6). First, all predictor variables were regressed onto the psychological
distress composite while controlling for covariates (age, education, race, gender expression,
romantic orientation, and SES) in one model. Then, interactions between each predictor variable
and resilience were regressed onto psychological distress. Interactions between predictor
variables were not explored. The results indicate that the model is significant and a good fit, with
approximately 41% of the variance accounted for by the relationship between minority stressors,
resilience, and gender identity beyond the covariates, R2 = .408, F(21, 248) = 8.13, p < .001, f2 =
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 89
.69. Resilience is a significant predictor of psychological distress, such that an increase in
resilience shows a -.31 SD decrease in psychological distress (β= -0.31, p= .02). Gender identity
(TGM versus TGW & GNC: β = -0.24, p = .39; TGW versus TGM & GNC: β = 0.25, p = .31),
vigilance (β = 0.40, p = .17), isolation (β = 0.14, p = .64), harassment & discrimination (β = -
0.25, p = .50), victimization (β = -0.03, p = .91), and gender expression minority stress (β =
0.09, p = .78) do not significantly predict psychological distress. Additionally, gender identity x
resilience (TGM versus TGW & GNC: β = 0.24, p = .38; TGW versus TGM & GNC: β = -0.31,
p = .22), vigilance x resilience (β = -0.21, p = .47), isolation x resilience (β = -0.09, p = .76),
harassment & discrimination x resilience (β = 0.27, p = .44), victimization x resilience (β = 0.06,
p = .83), and gender expression minority stress x resilience (β = 0.04, p = .91) do not
significantly predict psychological distress.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 90
Table 6
Hierarchical Multiple Regression Results for Psychological Distress With Gender Identity
Variable
B
95% CI for B
SE B
β
R2
ΔR2
LL
UL
Step 1
Intercept
39.12
34.41
43.82
2.39
.399
.399
TGM
-0.04
-1.82
1.74
0.90
0.00
TGW
-0.78
-2.57
1.01
0.91
-0.05
Vigilance
1.15
0.45
1.84
0.35
0.19**
Isolation
0.35
-0.30
1.00
0.33
0.06
H&D
0.07
-0.72
0.85
0.40
0.01
Victimization
0.27
-0.68
1.22
0.48
0.03
GEMS
0.79
-0.01
1.58
0.40
0.14
Resilience
-2.34
-3.06
1.61
0.37
-0.35***
Age
-0.12
-0.21
-0.03
0.05
-0.15**
Race
0.24
-0.18
0.67
0.22
0.06
Gender expression
-0.18
-0.63
0.28
0.23
-0.04
Romantic orientation
0.05
-0.40
0.50
0.23
0.01
Education
-0.33
-0.82
0.16
0.25
-0.07
SES
-0.31
-0.74
0.12
0.22
-0.08
Step 2
Intercept
37.70
29.02
46.38
4.41
.408
.009
TGM
-4.15
-13.68
5.38
4.84
-0.24
TGW
4.16
-4.00
12.29
4.13
0.25
Vigilance
2.38
-1.04
5.79
1.73
0.40
Isolation
0.77
-2.49
4.03
1.66
0.14
H&D
-1.40
-5.43
2.64
2.05
-0.25
Victimization
-0.27
-5.81
4.64
2.49
-0.03
GEMS
0.53
-3.12
4.18
1.85
0.09
Resilience
-2.02
-3.76
-0.28
0.88
-0.31*
Age
-0.13
-0.22
-0.04
0.05
-0.16**
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 91
Variable
B
95% CI for B
SE B
β
R2
ΔR2
LL
UL
Race
0.26
-0.18
0.70
0.22
0.06
Gender expression
-0.16
-0.63
0.31
0.24
-0.04
Romantic orientation
0.07
-0.39
0.53
0.23
0.02
Education
-0.33
-0.83
0.17
0.26
-0.07
SES
-0.25
-0.69
0.19
0.22
-0.06
TGM x Resilience
0.98
-1.22
3.17
1.11
0.24
TGW x Resilience
-1.10
-2.88
0.68
0.90
-0.31
Vigilance x Resilience
-0.28
-1.02
0.47
0.38
-0.21
Isolation x Resilience
-0.11
-0.82
0.60
0.36
-0.09
H&D x Resilience
0.36
-0.57
1.29
0.47
0.27
Victimization x Resilience
0.14
-1.09
1.36
0.62
0.06
GEMS x Resilience
0.05
-0.76
0.86
0.41
0.04
Note. CI = confidence interval; GEMS = gender expression minority stress; H&D = harassment and discrimination; LL =
lower limit; UL = upper limit. Race is dummy coded such that 0 indicates White and 1 indicates other races. There were
not enough people in each subcategory to code separately. Romantic orientation is dummy coded such that 0 indicates
aromantic and 1 indicates other romantic orientations. There were not enough people in each subcategory to code
separately. Gender identity is dummy coded such that TGM (0 = TGW, GNC, 1 = TGM); TGW (0 = TGM, GNC, 1 =
TGW); and GNC (0 = TGM, TGW, 1 = GNC). GNC is not included in the models which make all comparisons against
GNC individuals.
*p< .05. **p<.01. ***p< .001.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 92
Post Hoc Kruskal-Wallis H Tests
In addition to the planned analyses, a series of post-hoc Kruskal-Wallis H tests were
conducted to examine differences between mean scores on the variables of interest in the present
study between participants who met the cutoff score and those who did not. Multivariate
normality was tested using the Shapiro-Wilk tests of normality, which indicated that the data
were not normally distributed due to significant p-values. Because of the issue identified with
normality in assumptions testing, data transformations were attempted to correct for normality as
outlined by Lee (2020), but this was unsuccessful in correcting normality. As such, during the
analysis phase, the Kruskal-Wallis H tests were used instead of MANOVA, as per Finch’s
(2005) suggestion to use the Kruskal-Wallis test as a nonparametric test when assumptions are
violated for MANOVA. While this is not directly related to the hypotheses, it helps contextualize
study findings and allows for a more detailed discussion of asexual identification scale scores as
a variable. The results indicate that AIS scores, χ2(1) = 193.72, p < .001, η2 = .64 differed
significantly based on meeting the AIS cutoff score. Resilience, χ2(1) = 0.92, p = .34, η2 = -.007,
psychological distress, χ2(1) = 0.40, p = .53, η2 = -.009, harassment & discrimination, , χ2(1) =
2.11, p = .15, η2 = -.003, victimization, , χ2(1) = 0.66, p = .42, η2 = -.008, isolation, , χ2(1) =
0.30, p = .58, η2 = -.009, vigilance, χ2(1) = 0.29, p = .59, η2 = -.009, and gender expression
minority stress, , χ2(1) = 0.56, p = .45, η2 = -.008 did not significantly differ based on whether
participants met the AIS cutoff score.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 93
Chapter V – Discussion and Conclusions
Discussion of Findings
The primary goal of the current study was to examine gender expression minority stress,
proximal (vigilance and isolation), and distal minority stressors (harassment & discrimination
and victimization), resilience, gender identity, and the predictive relationship each factor has on
psychological distress in the asexual TGNC community. The first aim was to assess whether
there is a positive predictive relationship between minority stressors and psychological distress.
The second aim was to examine whether resilience moderates the relationship between minority
stressors and psychological distress. The third objective was to evaluate whether resilience
differs significantly based on gender identity. The fourth goal was to explore whether minority
stressors differs significantly based on gender identity. The fifth aim was examining whether
psychological distress differs significantly based on gender identity. The final objective was to
explore whether resilience moderates the relationship between minority stressors, gender
identity, and psychological distress. While several results of the study do not support the
hypotheses, the results may still convey the importance of minority stressors and resilience on
psychological distress and the importance of further examining gender identity differences
within the asexual TGNC community.
Hypothesis 1 predicted that the proximal and distal minority stressors assessed and
gender expression minority stress would positively predict psychological distress. This is
partially supported; the results show that participants experience more psychological distress
when they have more vigilance and gender expression minority stress. These results align,
respectively, with Hypotheses 1a and 1e. The results of this study partially support previous
research on the relationship between vigilance and gender expression minority stress on
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 94
psychological distress in TGNC and asexual individuals (Bockting et al., 2013; Brennan et al.,
2017; Hendricks & Testa, 2012; Lefevor et al., 2019; McInroy et al., 2020). A possible
explanation for this is vigilance, and gender expression minority stress could be the most salient
minority stressor related to psychological distress in the asexual TGNC community. This is
congruent with minority stress and gender minority stress theory, which suggests that
internalized or proximal stressors more directly predict psychological distress than distal
stressors because proximal stressors are internalized due to chronic external minority stress in
sexual and gender minority individuals (Meyer, 2003; Meyer et al., 2017; Testa et al., 2015).
The salience of vigilance and gender expression minority stress in the current study
relates to previous research on vicarious discrimination/trauma. Research indicates that vicarious
trauma in sexual and gender minority communities affects vigilance even when victimization and
harassment are not personally experienced because individuals exhibit heightened awareness and
a sense of vulnerability associated with having identities aligned with individuals who are
victims of hate crimes (Bell & Perry, 2015; Noelle, 2002). Similarly, Gonzalez et al. (2018)
found that vigilance increased among sexual and gender minority people, particularly among
TGNC individuals, after the 2016 presidential election and subsequent targeting of sexual and
gender minority communities. Qualitative research indicates that vigilance may include concerns
related to an increase in politicians attempting to restrict healthcare and public accommodations
access based on gender identity, as well as eliminating existing civil protections related to sexual
and gender identity (Bockting et al., 2020; Frederick et al., 2022). Relatedly, the media has
become increasingly antagonistic and has propagated transphobic messaging about TGNC
individuals, as illustrated by research on anxiety related to ballot referenda on gender-based civil
rights protections (Horne et al., 2022; Hughto et al., 2021). The current sociopolitical climate
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 95
could cause significant gender expression minority stress in the present study. When
experiencing greater antagonism in the sociopolitical sphere, TGNC individuals may respond
with more vigilance as a protective response to potential discrimination or harm (Nadal et al.,
2014). This is consistent with research that has shown that vigilance is used as a coping strategy
in some sexual and gender minority individuals (Alessi & Martin, 2017; Straussner & Calnan,
2014).
Hypothesis 1b posited that isolation would positively predict psychological distress and
this was not supported. Prior research indicates that isolation is heightened among asexual
individuals (Brotto et al., 2010; Dawson et al., 2018) and TGNC individuals (Bockting et al.,
2013; Hendricks & Testa, 2012). Individuals in the current study were recruited from affirming
online spaces for asexual- or TGNC-identified individuals and could have felt a sense of
community with other asexual or TGNC individuals. Research on the broader sexual and gender
minority communities supports the idea that LGBTQIA individuals have primarily socialized
online during the COVID-19 pandemic because of physical distancing (Scroggs et al., 2020).
Previous research indicates community in affirming LGBTQIA spaces among gender and sexual
minorities contributes to feeling less isolated, even if the identified community is solely online
(Brotto & Yule, 2009; Brotto et al., 2010; Fredriksen-Goldsen et al., 2013; Gonzalez et al., 2012;
Gupta, 2018; Riggle et al., 2008, 2011; Rostosky et al., 2010; Trujillo et al., 2016).
Hypotheses 1c and 1d examined whether harassment & discrimination and victimization,
respectively, would positively predict psychological distress, and this was not supported. Again,
harassment & discrimination and victimization may not have been significant because the sample
was recruited in affirming online social media spaces (e.g., Reddit and Facebook groups specific
to LGBTQIA communities). Because the Daily Heterosexist Experiences Questionnaire only
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 96
asks about experiences over the past 12 months, participants who had been social distancing
during the pandemic may not have had elevated distal or external minority stressors. Despite not
experiencing distal stressors, participants may still have heightened proximal stress from
previous distal stressor experiences, internalized self-stigma, and anticipation of future negative
distal stressor experiences (Meyer, 2003; Testa et al., 2015). The literature indicates that the
COVID-19 pandemic and social distancing may contribute to increased online socialization and,
for some LGBTQIA individuals, safety from distal stressors, such as harassment &
discrimination and victimization (Fish et al., 2020; Scroggs et al., 2020). This is similar to earlier
research indicating that online communication may be a source of resilience because resources,
information, positive space for finding role models, navigating identity, and self-expression are
more available to TGNC individuals in online communities (McInroy & Craig, 2015; Raun,
2015). Although general online socialization poses risks for harassment & discrimination and
victimization minority stress, the benefits of online socialization in affirming spaces offering
safety and support may result in comparably fewer opportunities for recent harassment &
discrimination and victimization (Craig et al., 2015; McInroy, 2019; McInroy & Craig, 2018).
The results of the present study suggest that future research may need to assess how much
socialization occurs online and what the quality of that socialization is like, especially as the
COVID-19 pandemic subsides.
Hypothesis 2 predicted that resilience would moderate the relationship between minority
stressors and psychological distress. The results of this study do not support this hypothesis.
However, the results support past research indicating that resilience negatively predicts
psychological distress among TGNC individuals (Bariola et al., 2015; Brennan et al., 2017;
Valente et al., 2020). These results are similar to Masten and Reed’s (2002) resilience theory that
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 97
psychological distress is negatively associated with higher resilience. Yet, the results are contrary
to what was expected, based on previous research indicating that resilience factors buffer
minority stress in sexual and gender minority populations (Meyer, 2003, 2015; Testa et al.,
2015).
An explanation for the lack of a moderation effect is that while the resilience scale in the
current study incorporates community resilience (e.g., family and peer resilience), which
research indicates is important to gender and sexual minority individuals (Moody & Smith, 2013;
Smith & Gray, 2009), it does not specifically relate to TGNC resilience. One study indicates that
family social support may not moderate the relationship between minority stressors and
depression in sexual and gender minority individuals (Chambi-Martínez et al., 2022).
Additionally, resilience cultivated in online spaces may require a higher frequency of
engagement (Craig & McInroy, 2015), and the scale does not measure this either. Finally,
research on intersectional racial/ethnic and sexual/gender minority communities indicates that
the connection to the intersectional community (i.e., TGNC people of color) could be salient in
facilitating resilience (Singh, 2013; Sung et al., 2015). Since participants were recruited in online
spaces for either TGNC or asexual individuals, they may not have had access to connections
with members of their intersectional community. A scale specific to intersectional TGNC
resilience could be important for detecting a moderation effect on the relationship between
minority stressors and psychological distress.
Hypothesis 3 predicted differences in resilience among asexual individuals depending on
their gender identity. The results of this study do not support this hypothesis. Previous literature
indicates differences in resilience based on gender identity in the TGNC community, with GNC
individuals showing higher resilience than TGM because of a stronger connection to the
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 98
LGBTQIA community and support from that community than TGM (Capuzza & Spencer, 2016;
Poquiz et al., 2021). TGW may show higher resilience than GNC individuals because of greater
visibility and involvement in the LGBTQIA community than GNC individuals (Capuzza &
Spencer, 2016; Poquiz et al., 2021; Warren et al., 2016).
A possible explanation for the unexpected findings of the current study could be the
emerging area of gender minority stress and resilience research in the TGNC community, and the
lack of methodological specificity in asking about differential experiences (Chavanduka et al.,
2020). This may cause significant differences in research samples to go undetected. Some
researchers also suggest asking about SAAB to assess differences in resilience within the TGNC
community more accurately (Thorne et al., 2019a). Individuals in the current study may have
similar levels of resilience because of homogeneity among their SAAB. Another possible
explanation for the unexpected results of the present study is the general nature of the resilience
questionnaire. Research by Simon et al. (2021) indicates that resilience questionnaires might
need to be specific to gender identity or sexual orientation to adequately detect differences. For
instance, while a family may be generally supportive, the family may invalidate the gender
identity or sexual identity of asexual TGNC individuals. Finally, the current study may not have
found significant differences in resilience between the groups because there may not be high
identity salience among asexual TGNC individuals regarding gender identity. Meyer (2015)
notes that “having a strong sense of identity can be a source of strength that inculcates the person
against an assault” (p. 210). Perhaps participants may not have a strong sense of TGNC identity
but do have a strong sense of asexual identity, which led to nonsignificant gender group
differences in resilience. Researchers argue that the meaning of one identity could depend on the
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 99
meaning of another identity (McConnell et al., 2018; Wagaman, 2016). Perhaps because asexual
identity goes against highly gendered norms, TGNC identity is less salient.
Hypothesis 4 predicted differences in minority stressors among asexual individuals
depending on gender identity. The results of this study partially support past research indicating
group differences in harassment & discrimination based on gender identity (Grant et al., 2011;
Schilt, 2012). Hypotheses 4e and 4f regarding significant differences in harassment &
discrimination based on gender identity were partially supported, with significant differences
based on gender detected. However, post-hoc analysis of the Kruskal-Wallis tests did not reveal
significant differences. Therefore, although there may be a significant difference in harassment
& discrimination, it is unclear where that difference lies. This may be because of unequal sample
sizes among groups (GNC individuals accounted for approximately half of the participants) and,
therefore, inadequate power for analysis contributing to Type I error (Rusticus & Lovato, 2014).
Findings regarding harassment and discrimination contrast with prior research indicating that
GNC individuals report more harassment and discrimination than TGW and TGM (Lefevor et
al., 2019). While post-hoc analysis did not reveal significant differences, TGM and TGW in the
current study have higher mean rank harassment and discrimination than GNC individuals. This
could be because of higher pressure among TGW and TGM to assume gendered sexual roles
(Cuthbert, 2019). Regarding minority stressors other than harassment & discrimination, no
significant differences were found based on gender identity. Participants may have had similar
levels of other minority stressors regardless of gender identity because confounding variables are
not analyzed in the present study. For instance, participants who are asexual and TGNC could
have placed less importance on their gender identity. Research indicates that identity salience is
positively associated with minority stress and psychological distress (Quinn et al., 2014;
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 100
Syzamanski & Sung, 2010), and low identity salience in the current study may have led to
similar amounts of minority stress across gender identities.
Another reason for the non-significant group differences could be the internalization of
similar stress levels, regardless of subgroup identity. Research on race/ethnicity-related minority
stress by Turner and Smith (2015) found no significant group differences based on race/ethnicity
in stress levels; they argued that this could be related to the internalization of similar stress levels
among participants regardless of racial/ethnic groups. In the current study, significant differences
in minority stressors may not have been located because identifying as asexual and TGNC,
regardless of gender identity, means violating gendered sexual scripts (Cuthbert, 2019). This
could have caused participants to experience similar levels of internalization of other minority
stressors regardless of gender identity.
Hypothesis 5 predicted differences in psychological distress among asexual individuals
depending on their gender identity. The results of this study do not support Hypothesis 5.
Previous literature indicates differences in psychological distress based on gender identity in the
TGNC community, with TGW displaying higher psychological distress than TGM and GNC
individuals showing higher psychological distress than TGW (Cicero et al., 2020; Crissman et
al., 2019; Millet et al., 2017; Rimes et al., 2019; Thorne et al., 2019a; Warren et al., 2016). A
possible explanation for the unexpected findings is that SAAB could be a factor in psychological
distress. Research indicates that AFAB individuals show higher rates of psychological distress
and if AFAB individuals are oversampled, this can obscure subgroup differences based on
gender identity (Parodi et al., 2022; Rimes et al., 2019). Previous research also indicates that a
significantly greater proportion of individuals AFAB may participate in TGNC research (Todd et
al., 2019), and some researchers have suggested oversampling individuals AMAB to correct for
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 101
this and diversify the participant sample (Kyweluk et al., 2018). Because this study does not ask
about SAAB, individuals in the study may have had similar amounts of psychological distress
because of homogeneity in the variable SAAB. Finally, it is possible that the pandemic and
social isolation meant less potential for different experiences of resilience and minority stressors
among gender identity groups, and perhaps contributed to equivalence among groups of
psychological distress (Scroggs et al., 2020). The pandemic may have caused LGBTQIA
participants to focus more on other stressors and to have similar experiences of minority stress
and resilience, regardless of subgroup identity.
Hypothesis 6 predicted that resilience would moderate the relationship between minority
stress, gender identity, and psychological distress. The results of this study do not support that
hypothesis. Similar to the present study, Puckett et al. (2020b) found a lack of a moderation
effect of resilience on minority stress and psychological distress among TGNC individuals and
attributed this to a lack of ways to measure TGNC resilience factors (e.g., challenging gender
norms and engaging in behaviors to affirm one’s experience of gender) identified in qualitative
research (Budge et al., 2017; Mizock & Mueser, 2014). While not significant as a moderator, the
relationship between minority stress and psychological distress may have been weakened, such
that minority stressors became non-significant in the model, as in Sarno et al.’s (2020) research.
In addition, the lack of significance in the current study could be due to the influence of the
COVID-19 pandemic and social distancing on the validity of the study results (Mara & Peugh,
2020). To correct for this, Mara and Peugh (2020) suggest that researchers administer a COVID-
19 impact questionnaire to assess potential moderation or mediation effects of COVID-19 on
distress. As this was not done, it is unknown whether COVID-19 stress affected the results of the
current study.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 102
Limitations
The present study has several limitations that could inform future research on the asexual
TGNC community. First, there are unequal groups based on gender identity, with GNC
individuals accounting for over half of the sample and TGM and TGW each accounting for less
than 25% of the sample. In addition to limiting generalizability, unequal groups contribute to the
failure of the assumption of multivariate normality for the MANOVA test and the decision to use
non-parametric Kruskal-Wallis tests. Another limitation related to generalizability is the
racial/ethnic homogeneity of the sample. While efforts were made to recruit diverse participants,
the sample was overwhelmingly (approximately 75%) White. This mirrors previous research, as
indicated by Guz et al.’s (2022) scoping review of asexuality research, indicating that the present
study’s findings may not represent the overall population. Finally, while outside the scope of the
current study, the sample size was not large enough to perform analyses of subscales related to
community resilience, and research indicates that this type of resilience is especially important
(Moody & Smith, 2013; Smith & Gray, 2009). Future researchers using the PFRS for sexual and
gender minority research should consider using sufficiently large sample sizes for subscale
analyses.
Another limitation of this study is the lack of validated measures for use with asexual
TGNC individuals. The DHEQ scale used for assessing minority stressors was normed on LGBT
individuals, and not all questions for each type of minority stressor are pertinent for asexual
individuals, which could explain the unexpected results indicating no differences among
minority stressors other than harassment & discrimination based on the gender identity of
participants. Other research calls for a scale for the measurement of asexual-related minority
stress (Foster, 2017), similar to the DHEQ, which could have helped analyze the study results to
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 103
see whether controlling for asexuality-related minority stress would help detect differences
among participants based on gender identity. The PFRS scale was also not normed on asexual
individuals, nor was it normed on TGNC individuals. It is possible that measurement error and
the scale not being sensitive to unique resilience factors for those holding an asexual identity
contributed to some of the unexpected findings in the current study. In addition to the lack of
scale validation with members of the asexual community, self-report measures are susceptible to
construct validity problems and response bias, which could have affected the current study’s
results (Lance & Vandenberg, 2009).
A similar limitation of the present study is that the lack of assessment of identity salience
could have confounded the results. Identity centrality is a minority stress process according to
minority stress theory (Meyer, 2003). Heightened stress associated with a salient identity among
intersectional sexual and gender minority individuals, may be detrimental to health and positive
identity development (Sarno et al., 2021). Among racial/ethnic minority sexual and gender
minority individuals, if multiple identities are salient and minority stress is associated with each
of their identities, there could be even more detrimental effects on health (Balsam et al., 2011;
Fattoracci et al., 2021). Detrimental health outcomes could be especially likely if there is identity
conflict between the identities of sexual and gender minority and racial and ethnic minority
individuals (Jackson et al., 2020; Santos & VanDaalen, 2016, 2018). Asexual people with an
intersecting identity may also have detrimental health impacts, especially if both identities are
salient. Research is limited, but suggests that asexual people of color who consider both
identities salient may lack a sense of belonging and face more stigmatizing experiences, which
may impact mental health (Foster et al., 2018).
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 104
An additional limitation of this study is the possibility that COVID-19 could be acting as
a variable affecting the study results because of history effects. While collecting data during this
unique time could add to the literature base, it is a limitation of this study because there was no
questionnaire used to assess and control the impact of COVID-19-related distress. The pandemic,
a hostile sociopolitical climate, and increased targeting of the LGBTQIA community could have
impacted recruitment and affected the characteristics of participants who opted to participate in
the study. This is why researchers like Bleckmann et al. (2022) call for longitudinal research on
sexual and gender minorities to account for potential history effects.
A final limitation is that SAAB demographic information was not collected because
research indicates some TGNC individuals find questions about their SAAB stigmatizing (Alpert
et al., 2022; Puckett et al., 2020a). However, some studies indicate that differences may exist in
minority stress and psychological distress associated with SAAB within the TGNC community
(Bockting et al., 2013; Hendricks & Testa, 2012). There may also be differences in the
experiences of resilience associated with the SAAB of TGNC individuals (Chavanduka et al.,
2020; Newcomb et al., 2020). Not having information regarding SAAB could have affected the
ANOVA and Kruskal-Wallis tests; furthermore, it limits information concerning the
generalizability of the sample collected.
Directions for Future Research
The present study elucidates more understanding of the effects of minority stress and
resilience on psychological distress among asexual TGNC individuals. However, using other
research methods to study this community may provide a more nuanced understanding. The
current study used an online cross-sectional convenience sample that provided limited
information regarding the causality of the observed relationships. A repeated-measures
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 105
longitudinal approach could help mitigate limitations associated with cross-sectional research,
such as the history effects associated with the COVID-19 pandemic.
The correlation data in the present study also present potential avenues for future
research. There were significant negative correlations between psychological distress and age (r
= -.22, p ≤ .01), socioeconomic status (r = -.21, p ≤ .01), and education level (r = -.17, p ≤ .01).
As age, socioeconomic status, and education level increased, psychological distress decreased.
Age (β = -0.l7, p = .01), socioeconomic status (β = -0.13, p = .03), and education level (β = -
0.12, p = .02) were also significant as covariates in the regression model, negatively predicting
psychological distress. Age was also a significant covariate in the hierarchical linear regression
models without gender identity (β = 0.17, p = .003) and with gender identity (β = 0.16, p = .008)
as a negative predictor of psychological distress. These findings raise questions regarding
whether these variables buffer the relationship between minority stress and psychological
distress among asexual TGNC people, similar to previous research indicating a buffering role of
each of these variables on the psychological distress of TGNC individuals (Breslow et al., 2015).
A longitudinal investigation into the relationship between age, socioeconomic status, education
level, and psychological distress among asexual TGNC individuals may more fully explain the
correlations observed in this study.
Future research may also benefit from better measurement of asexuality. Better
measurement of asexuality could include collecting larger sample sizes and breaking down the
analysis by subgroups within the asexual spectrum because of differential experiences within the
asexual community. For instance, demisexual individuals may be more likely to be perceived as
allosexual (Clark et al., 2022; Kelleher et al., 2022). In addition, for the purpose of this study,
those who self-identified as asexual were included regardless of their AIS scores. The AIS has
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 106
historically been used as a measure with a cut-off score to identify those who are asexual. Only
68% of the sample in the present study met the cutoff score used by Yule et al. (2015) to identify
asexual individuals. Previous research indicates that over 90% of self-identified asexual
individuals meet the AIS cutoff score (Yule et al., 2015; Zheng & Su, 2018). This suggests that
the scale may not be as useful as a measure of the asexual TGNC population as it is for the
general asexual community. Post-hoc Kruskal-Wallis tests indicate that the issues with the AIS
scale may not have affected the present study’s results, yet refinement of this scale is still a
possible direction for future research.
Additionally, future research on asexual TGNC minority stress, resilience, and
psychological distress may benefit from incorporating qualitative data collected through
interviews. Prior qualitative research on the asexual community could yield information about
the community’s unique experiences (Prause & Graham, 2007; Scherrer, 2008) that could inform
subsequent quantitative research. Narrative exploration of how an asexual TGNC person’s
minority stress and resilience fluctuates over time and how it influences psychological distress
may provide additional information and themes that explain the experiences of psychological
distress and how to mitigate that distress. This could also reveal other factors with the potential
to moderate the relationship between minority stress and psychological distress.
Despite the limitations of the present study and the factors that future researchers may
need to consider, the findings of this study suggest that experiences of vigilance and gender
expression minority stress negatively impact the mental health of asexual TGNC individuals.
Although resilience did not buffer psychological distress, it was a negative predictor of
psychological distress, suggesting that it is important to continue exploring in future mental
health research. In addition, harassment & discrimination may be particularly important to assess
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 107
because of the potential for different experiences of that minority stressor among subgroups
within the asexual TGNC community.
Clinical, Social, and Theoretical Implications
Clinical Implications
Many therapists lack adequate training and guidance to competently treat asexual (Foster
& Scherrer, 2014) and transgender clients (Singh & dickey, 2017). The current study's findings
may have implications for healthcare professionals and their ability to provide better targeted and
culturally competent care for asexual TGNC individuals (Foster & Scherrer, 2014). By
developing a further understanding of the unique effects of vigilance and gender expression
minority stress on the psychological distress faced by this community, healthcare professionals
could be better able to provide targeted treatment of psychological distress in this community.
For example, regarding vigilance and gender expression minority stress, clinicians can alleviate
the psychological impact of stressors by using guidelines like those developed by the APA. To
do this, clinicians should validate that stigmatizing societal culture causes stress; provide
psychoeducation on the effects of those stressors; and use interventions, such as mindfulness and
cognitive-behavioral interventions, to alleviate the psychological impact of those stressors (APA,
2013, 2021). It is imperative that therapists working with asexual TGNC clients be well informed
about current standards of care that emphasize individualized, person-centered care that is
mindful of intersectional identities. Clinicians are encouraged not to make assumptions when
working with asexual TGNC clients; instead, clinicians should be empathic and open-minded
when discussing experiences of discrimination (APA 2013, 2021; Meyer, 2003; Testa et al.,
2015). Based on the results of the current study, assessing levels of harassment and
discrimination as they relate to gender identity may be critical to case conceptualization because
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 108
there may be significant differences based on gender identity within the asexual TGNC
community.
Affirming therapy that focuses on mitigating unique risk factors while amplifying
specific protective factors is paramount for positive health outcomes in the LGBTQIA
community (Butler et al., 2019; Kattari et al., 2016; Lelutiu-Weinberger & Pachankis, 2017;
Pepping et al., 2018). Despite the absence of a moderation relationship, the negative predictive
relationship between resilience and psychological distress in the present study indicates the
importance of protective factors. The elevated psychological distress consistent with a moderate
mental disorder (M = 27.89, SD = 6.93) identified among participants in the present study, using
the K10 cutoff scores by Andrews and Slade (2001), underscores the importance of increasing
resilience among asexual TGNC individuals. While outside the scope of the present study, two of
the protective factors that could be particularly important for clinicians to focus on enhancing
include social support and family support (Bariola et al., 2015; Chambi- Martínez et al., 2022;
Foster & Scherrer, 2014; Gower et al., 2018; Hendricks & Testa, 2012; Puckett et al., 2019). The
present study contributes to an improved understanding of the asexual TGNC community, which
could facilitate LGBTQIA cultural competency trainers’ ability to better educate healthcare
professionals regarding underrepresented communities within the LGBTQIA community (Pratt-
Chapman et al., 2022). Improved cultural competency in working with asexual TGNC
individuals could help increase their access to positive therapeutic experiences.
The purpose and findings of the present study align with the APA (2021) Guidelines for
Practice with Sexual Minority Persons, which state, “asexual persons may be underrepresented in
the psychological literature and more research is needed to provide them with appropriate
psychological services” (p. 5). The developers of national cultural competency standards for
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 109
sexual and gender minority clients also argue for affirming care adaptable to different sexual and
gender minority identity groups based on their unique challenges (Pratt-Chapman et al., 2022).
More trans-inclusive, asexual-inclusive, and intersectionality-focused competency training
through conferences and continuing education workshops could help improve the provision of
effective clinical care even if formal training programs do not provide instruction in these
content areas.
Social Implications
The present study represents a step toward increased understanding and social awareness
of those who are asexual and TGNC, which aligns with APA’s (2021) Guidelines for Practice
with Sexual Minority Persons. These guidelines call for psychologists to advocate for creating
spaces for historically excluded sexual minority persons with intersectional identities to thrive.
Increased visibility and less stigmatization of asexual TGNC individuals may help increase
resources in LGBTQIA community spaces and alleviate unsuccessful attempts at community
connection (Cuthbert, 2019; Simon et al., 2021). For instance, in LGBTQIA community spaces,
asexual TGNC individuals may often feel excluded because of stigmatizing views from the
overall LGBTQIA community (Cuthbert, 2019; Sumerau, 2018). If awareness increases,
LGBTQIA community spaces could offer a place for asexual TGNC individuals to receive peer
and community support. Increased support may help asexual TGNC individuals cope with
heightened minority stressors, such as vigilance and gender expression minority stress, and
experience less psychological distress. Research indicates that TGNC individuals (Bockting et
al., 2016; White, 2013) and sexual minority individuals (Meyer, 2003; Foster et al., 2019) may
find community connection especially salient to resilience and effectively coping with minority
stressors, with positive implications for improved mental health (Testa et al., 2015; Thorne et al.,
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 110
2019a). Community connection could be particularly important in facilitating the moderation of
the relationship between minority stress and psychological distress.
Increased awareness, knowledge, and community spaces may be particularly important
for children and adolescents increasingly identifying with multiple sexual and gender minority
identities (The Trevor Project, 2020). Increased social awareness and community support could
yield public health benefits such as reduced psychological distress and a less taxed mental health
system (Badgett et al., 2019). Improving social awareness and community support could occur
through (a) more intersectionality-focused programming and public awareness campaigns at
community centers, (b) expanding non-discrimination policies in states and localities that do not
have non-discrimination protections, (c) LGBTQIA-affirming parenting resources and public
messaging, and (d) safe climate initiatives at schools and colleges (Bariola et al., 2015; Casey et
al., 2019; Cicero et al., 2020; Gower et al., 2018; James et al., 2016; Meyer, 2015; McInroy et
al., 2020; Mollet & Lackman, 2018; Simon et al., 2021). In addition to these supports and
resources acting as resilience factors, they could also facilitate asexual TGNC individuals being
more likely to complete higher levels of education and obtain employment. In the current study,
education level and socioeconomic status are negative predictors of psychological distress, which
aligns with research on the overall TGNC community (Bariola et al., 2015).
Theoretical Implications
It is hoped that this research and its findings will expand future research and social
awareness of asexual TGNC individuals. This study may be a starting point for a unique model
of minority stress like Testa et al.’s (2015) and Lefevor et al.’s (2019) models of gender minority
stress and genderqueer minority stress. These models both added, removed, and changed
variables from Meyer’s (2003) minority stress model to adapt to specific subpopulations within
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 111
the LGBTQIA community. In the asexual TGNC community, the findings of the present study
could indicate that vigilance and gender expression minority stress are variables of importance to
a unique model of minority stress. Previous research by Hendricks and Testa (2012) shows
TGNC individuals who also hold sexual minority identities have higher proximal stressors,
including vigilance and gender-related identity concealment, and research by McInroy et al.
(2020) shows proximal stressors may be higher among asexual TGNC individuals. Further
development of scales to assess minority stressors specific to asexual TGNC individuals is
critical to developing a unique model of minority stress. The current study underscores the
importance of proximal stressors (i.e., vigilance and gender expression minority stress) in
predicting psychological distress among asexual TGNC individuals, which fits with Meyer’s
(2003) minority stress theory, and shows that these particular stressors might be particularly
salient in the intersecting community. Additionally, the current study's findings affirm Masten
and Reed’s (2002) resilience theory and the negative predictive relationship between resilience
and psychological distress. Finally, the current study focuses on individuals who hold
intersectional sexual and gender minority identities, which researchers, like Williams et al.
(2020), have called for because of the potential for uniquely negative minority stressors and
psychological distress.
Conclusion
Overall, this study clarifies the role of minority stressors, gender identity, and resilience
on psychological distress to better understand how the asexual TGNC community self-reports
gender expression minority stress, proximal (isolation and vigilance), and distal stressors
(harassment & discrimination and victimization), resilience, and gender identity experiences, as
well as whether these variables predict psychological distress. Vigilance and gender expression
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 112
minority stress are significant positive predictors of psychological distress, which may have
implications for areas to be targeted in treatment of asexual TGNC individuals. In addition,
resilience is a significant negative predictor of psychological distress, despite its non-significance
as a moderator, which highlights the importance of protective factors for the asexual TGNC
community. Additionally, the results indicate potentially significant group differences in
harassment & discrimination minority stress, depending on the gender identity of the
participants. The results of this study can help clinicians better understand that harassment &
discrimination could differ based on gender identity, assisting in tailored case conceptualization
and intervention depending on the gender identity of clients. Individualized conceptualization
and intervention may result in improved psychological functioning, treatment outcomes, and
quality of life among asexual TGNC individuals. This study may aid researchers, clinicians,
policymakers, health professional training curriculum leaders, and LGBTQIA community
leaders in focusing on specific minority stressors and resilience factors that affect psychological
distress among asexual TGNC individuals.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 113
References
Ajzen, I., & Fishbein, M. (2005). The influence of attitudes on behavior. In D. Albarracin, B. T.
Johnson, & M. P. Zanna (Eds.), The handbook of attitudes, volume 1: Basic principles
(pp. 173–221). Routledge.
Alessi, E. J., & Martin, J. I. (2017). Intersection of trauma and identity. In K. L. Eckstrand & J.
Potter (Eds.), Trauma, resilience, and health promotion in LGBT patients: What every
healthcare provider should know (pp. 3-14). Springer.
Alpert, A. B., Mehringer, J. E., Orta, S. J., Redwood, E., Hernandez, T., Rivers, L., Manzano, C.,
Ruddick, R., Adams, S., Cerulli, C., Operario, D., & Griggs, J. J. (2022). Experiences of
transgender people reviewing their electronic health records, a qualitative study. Journal
of General Internal Medicine. https://doi.org/10.1007/s11606-022-07671-6
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(DSM-5). American Psychiatric Publishing.
American Psychological Association. (2013). Guidelines for psychological practice with
transgender and gender nonconforming people.
https://www.apa.org/practice/guidelines/transgender.pdf
American Psychological Association. (2021). Guidelines for psychological practice with sexual
minority persons.
https://www.apa.org/about/policy/psychological-sexual-minority-persons.pdf
Andresen, E. M., Malmgren, J. A., Carter, W. B., & Patrick, D. L. (1994). Screening for
depression in well older adults: Evaluation of a short form of the CES-D. American
Journal of Preventive Medicine, 10(2), 77–84. https://doi.org/10.1016/s0749-
3797(18)30622-6
Andrews, G., & Slade, T. (2001). Interpreting scores on the Kessler Psychological Distress Scale
(K10). Australian and New Zealand Journal of Public Health, 25(6), 494–497.
https://doi.org/10.1111/j.1467-842x.2001.tb00310.x
Aparicio-García, M., Díaz-Ramiro, E., Rubio-Valdehita, S., López-Núñez, M., & García-
Nieto, I. (2018). Health and well-being of cisgender, transgender and nonbinary young
people. International Journal of Environmental Research and Public Health, 15(10), 21–
33. https://doi.org/10.3390/ijerph15102133
Arcelus, J., Claes, L., Witcomb, G. L., Marshall, E., & Bouman, W. P. (2016). Risk factors for
non-suicidal self-injury among trans youth. The Journal of Sexual Medicine, 13(3), 402–
412. https://doi.org/10.1016/j.jsxm.2016.01.003
Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling. (2009).
Competencies for counseling with transgender clients.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 114
https://www.counseling.org/Resources/Competencies/ALGBTIC_Competencies.pdf
Badgett, M. L., Waaldijk, K., & Rodgers, Y. V. (2019). The relationship between LGBT
inclusion and economic development: Macro-level evidence. World Development, 120,
1–14. https://doi.org/10.1016/j.worlddev.2019.03.011
Badgett, M. L., Baker, K. E., Conron, K. J., Gates, G. J., Gill, A., Greytak, A., & Herman, J. L.
(2014, September). Best practices for asking questions to identify transgender and other
gender minority respondents on population-based surveys (GenIUSS). Williams Institute.
https://williamsinstitute.law.ucla.edu/publications/geniuss-trans-pop-based-survey/
Balsam, K. F., Beadnell, B., & Molina, Y. (2013). The Daily Heterosexist Experiences
Questionnaire. Measurement and Evaluation in Counseling and Development, 46(1), 3–
25. https://doi.org/10.1177/0748175612449743
Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple
minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity
and Ethnic Minority Psychology, 17, 163-174. https://doi.org/10.1037/a0023244
Bariola, E., Lyons, A., Leonard, W., Pitts, M., Badcock, P., & Couch, M. (2015). Demographic
and psychosocial factors associated with psychological distress and resilience among
transgender individuals. American Journal of Public Health, 105(10), 2108-2116.
https://doi.org/10.2105/ajph.2015.302763
Barr, S. M., Budge, S. L., & Adelson, J. L. (2016). Transgender community belongingness as a
mediator between strength of transgender identity and well-being. Journal of Counseling
Psychology, 63(1), 87–97. https://doi.org/10.1037/cou0000127
Bastian, B., & Haslam, N. (2010). Excluded from humanity: The dehumanizing effects of social
ostracism. Journal of Experimental Social Psychology, 46(1), 107-113.
https://doi.org/10.1016/j.jesp.2009.06.022
Bauer, C., Kaye, S. L., & Brotto, L. A. (2019). Understanding alcohol and tobacco consumption
in asexual samples: A mixed-methods approach. Archives of Sexual Behavior, 49(2),
733–755. https://doi.org/10.1007/s10508-019-01570-4
Bauer, C., Miller, T., Ginoza, M., Guo, Y., Youngblom, K., Baba, A., & Adroit, M. (2018). The
2016 Asexual Community Survey summary report. The Asexual Community Survey
Team.
https://asexualcensus.files.wordpress.com/2018/11/2016_ace_community_survey_report.
pdf
Bauerband, L. A., & Galupo, M. P. (2014). The gender identity reflection and rumination scale:
Development and psychometric evaluation. Journal of Counseling & Development,
92(2), 219–231. https://doi.org/10.1002/j.1556-6676.2014.00151.x
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 115
Bell, J. G., & Perry, B. (2015). Outside looking in: The community impacts of anti-lesbian, gay,
and bisexual hate crime. Journal of Homosexuality, 62(1), 98-120.
https://doi.org/10.1080/00918369.2014.957133
Benjamin, H. (1966). The transsexual phenomenon: A scientific report on transsexualism and
sex conversion in the human male and female. Julian Press.
Bennett, D. A. (2001). How can I deal with missing data in my study? Australian and New
Zealand Journal of Public Health, 25(5), 464-469. https://doi.org/10.1111/j.1467-
842x.2001.tb00294.x
Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., Sapareto, E., &
Ruggiero, J. (1994). Initial reliability and validity of a new retrospective measure of child
abuse and neglect. American Journal of Psychiatry, 151(8), 1132–1136.
https://doi.org/10.1176/ajp.151.8.1132
Bidell, M. P. (2013). Addressing disparities: The impact of a lesbian, gay, bisexual, and
transgender graduate counselling course. Counselling and Psychotherapy Research,
13(4), 300-307. https://doi.org/10.1080/14733145.2012.741139
Bishop, G. F. (2008). Item order randomization. In P. J. Lavrakas (Ed.), Encyclopedia of survey
research methods (pp. 397–399). SAGE Publications.
Bleckmann, C., Leyendecker, B., & Busch, J. (2022). Sexual and gender minorities facing the
coronavirus pandemic: A systematic review of the distinctive psychosocial and health-
related impact. Journal of Homosexuality, 1-22.
https://doi.org/10.1080/00918369.2022.2074335
Blosnich, J. R., Marsiglio, M. C., Gao, S., Gordon, A. J., Shipherd, J. C., Kauth, M.,
Brown, G. R., & Fine, M. J. (2016). Mental health of transgender veterans in US states
with and without discrimination and hate crime legal protection. American Journal of
Public Health, 106(3), 534–540. https://doi.org/10.2105/ajph.2015.302981
Bockting, W., Barucco, R., LeBlanc, A., Singh, A., Mellman, W., Dolezal, C., & Ehrhardt, A.
(2020). Sociopolitical change and transgender people’s perceptions of vulnerability and
resilience. Sexuality Research and Social Policy, 17(1), 162-174.
https://doi.org/10.1007/s13178-019-00381-5
Bockting, W., & Coleman, E. (2016). Developmental stages of the transgender coming-out
process. In R. Ettner, S. Monstrey, & E. Coleman (Eds.), Principles of transgender
medicine and surgery (pp. 137–158). Taylor and Francis.
Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013).
Stigma, mental health, and resilience in an online sample of the US transgender
population. American Journal of Public Health, 103(5), 943–951.
https://doi.org/10.2105/ajph.2013.301241
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 116
Bockting, W., Robinson, B., Benner, A., & Scheltema, K. (2004). Patient satisfaction with
transgender health services. Journal of Sex & Marital Therapy, 30(4), 277–294.
https://doi.org/10.1080/00926230490422467
Bogaert, A. F. (2004). Asexuality: Prevalence and associated factors in a national probability
sample. The Journal of Sex Research, 41(3), 279–287.
https://doi.org/10.1080/00224490409552235
Bogaert, A. F. (2006). Toward a conceptual understanding of asexuality. Review of General
Psychology, 10(3), 241–250. https://doi.org/10.1037/1089-2680.10.3.241
Bogaert, A. F. (2012). Understanding asexuality. Rowman & Littlefield Publishers.
Bogaert, A. F. (2016). What asexuality tells us about sexuality. Archives of Sexual Behavior,
46(3), 629–630. https://doi.org/10.1007/s10508-016-0892-2
Borgogna, N. C., McDermott, R. C., Aita, S. L., & Kridel, M. M. (2018). Anxiety and depression
across gender and sexual minorities: Implications for transgender, gender
nonconforming, pansexual, demisexual, asexual, queer, and questioning individuals.
Psychology of Sexual Orientation and Gender Diversity, 6(1), 54–63.
https://doi.org/10.1037/sgd0000306
Bouman, W. P., Claes, L., Brewin, N., Crawford, J. R., Millet, N., Fernandez-Aranda, F., &
Arcelus, J. (2017). Transgender and anxiety: A comparative study between transgender
people and the general population. International Journal of Transgenderism, 18(1), 16–
26. https://doi.org/10.1080/15532739.2016.1258352
Bowleg, L. (2012). The problem with the phrase “women and minorities”: Intersectionality, an
important theoretical framework for public health. American Journal of Public Health,
102(7), 1267–1273. https://doi.org/10.2105/AJPH.2012.300750
Bradford, N. J., & Catalpa, J. M. (2019). Social and psychological heterogeneity among binary
transgender, nonbinary transgender and cisgender individuals. Psychology & Sexuality,
10(1), 69–82. https://doi.org/10.1080/19419899.2018.1552185
Brennan, S. L., Irwin, J., Drincic, A., Amoura, N. J., Randall, A., & Smith-Sallans, M. (2017).
Relationship among gender-related stress, resilience factors, and mental health in a
midwestern U.S. transgender and gender-nonconforming population. International
Journal of Transgenderism, 18(4), 433–445.
https://doi.org/10.1080/15532739.2017.1365034
Breslow, A. S., Brewster, M. E., Velez, B. L., Wong, S., Geiger, E., & Soderstrom, B. (2015).
Resilience and collective action: Exploring buffers against minority stress for transgender
individuals. Psychology of Sexual Orientation and Gender Diversity, 2(3), 253–265.
https://doi.org/10.1037/sgd0000117
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 117
Brotto, L. A., Knudson, G., Inskip, J., Rhodes, K., & Erskine, Y. (2010). Asexuality: A mixed-
methods approach. Archives of Sexual Behavior, 39(3), 599–618.
https://doi.org/10.1007/s10508-008-9434-x
Brotto, L. A., & Yule, M. A. (2009). Reply to Hinderliter. Archives of Sexual Behavior, 38, 622–
623. https://doi.org/10.1007/s10508-009-9502-x
Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual
desire disorder? The Journal of Sexual Medicine, 12(3), 646–660.
https://doi.org/10.1111/jsm.12806
Bruce, D., Harper, G. W., & Bauermeister, J. A. (2015). Minority stress, positive identity
development, and depressive symptoms: Implications for resilience among sexual
minority male youth. Psychology of Sexual Orientation and Gender Diversity, 2(3), 287–
296. https://doi.org/10.1037/sgd0000128
Budge, S. L., Adelson, J. L., & Howard, K. A. (2013). Anxiety and depression in transgender
individuals: The roles of transition status, loss, social support, and coping. Journal of
Consulting and Clinical Psychology, 81(3), 545–557. https://doi.org/10.1037/a0031774
Budge, S. L., Chin, M. Y., & Minero, L. P. (2017). Trans individuals’ facilitative coping: An
analysis of internal and external processes. Journal of Counseling Psychology, 64(1), 12-
25. https://doi.org/10.1037/cou0000178
Budge, S. L., Rossman, H. K., & Howard, K. A. (2014). Coping and psychological distress
among genderqueer individuals: The moderating effect of social support. Journal of
LGBT Issues in Counseling, 8(1), 95–117.
https://doi.org/10.1080/15538605.2014.853641
Burgwal, A., Gvianishvili, N., Hård, V., Kata, J., García Nieto, I., Orre, C., Smiley, A., Vidíc, J.,
& Motmans, J. (2020). Health disparities between binary and non binary trans people: A
community-driven survey. Non-binary and Genderqueer Genders, 20(1-2), 100–111.
https://doi.org/10.1080%2F15532739.2019.1629370
Butler, R. M., Horenstein, A., Gitlin, M., Testa, R. J., Kaplan, S. C., Swee, M. B., &
Heimberg, R. G. (2019). Social anxiety among transgender and gender nonconforming
individuals: The role of gender-affirming medical interventions. Journal of Abnormal
Psychology, 128(1), 25–31. https://doi.org/10.1037/abn0000399
Calabrese, S. K., Meyer, I. H., Overstreet, N. M., Haile, R., & Hansen, N. B. (2014). Exploring
discrimination and mental health disparities faced by Black sexual minority women using
a minority stress framework. Psychology of Women Quarterly, 39(3), 287–304.
https://doi.org/10.1177/0361684314560730
Caldwell, S. (2013). Statistics unplugged (4th ed.). Wadsworth, Cengage Learning.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 118
Capuzza, J. C., & Spencer, L. G. (2016). Regressing, progressing, or transgressing on the small
screen? Transgender characters on U.S. scripted television series. Communication
Quarterly, 65(2), 214–230. https://doi.org/10.1080/01463373.2016.1221438
Carrigan, M. (2011). There’s more to life than sex? Difference and commonality within the
asexual community. Sexualities, 14(4), 462-478.
https://doi.org/10.1177/1363460711406462
Carvalho, J., Lemos, D., & Nobre, P. J. (2016). Psychological features and sexual beliefs
characterizing self-labeled asexual individuals. Journal of Sex & Marital Therapy, 43(6),
517-528. https://doi.org/10.1080/0092623x.2016.1208696
Casey, L. S., Reisner, S. L., Findling, M. G., Blendon, R. J., Benson, J. M., Sayde, J. M., &
Miller, C. (2019). Discrimination in the United States: Experiences of lesbian, gay,
bisexual, transgender, and queer Americans. Health Services Research, 54, 1454–1466.
https://doi.org/10.1111/1475-6773.13229
Cerankowski, K. J., & Milks, M. (2010). New orientations: Asexuality and its implications for
theory and practice. Feminist Studies, 36(3), 650–664. https://doi.org/10.2307/27919126
Chambi-Martínez, C. A., Moraga-Escobar, E. I., Peralta-Jiménez, G. A., Vera-Calzaretta, A.,
Barrientos, J., Pihán, R., Klaassen, G., & Páez, D. (2021). Social support, stress and
emotional symptoms among LGBTQ+ College students in Chile. International Journal of
Sexual Health, 34(2), 277-290. https://doi.org/10.1080/19317611.2021.2014014
Chasin, C. D. (2011). Theoretical issues in the study of asexuality. Archives of Sexual Behavior,
40(4), 713–723. https://doi.org/10.1007/s10508-011-9757-x
Chavanduka, T. M., Gamarel, K. E., Todd, K. P., & Stephenson, R. (2020). Responses to the
gender minority stress and resilience scales among transgender and nonbinary youth.
Journal of LGBT Youth, 18(2), 135–154.
https://doi.org/10.1080/19361653.2020.1719257
Cicero, E. C., Reisner, S. L., Merwin, E. I., Humphreys, J. C., & Silva, S. G. (2020). The health
status of transgender and gender nonbinary adults in the United States. PLOS ONE,
15(2), e0228765. https://doi.org/10.1371/journal.pone.0228765
Clark, A. N., Lefkowitz, E. S., & Zimmerman, C. (2022). Sexual and affectionate behaviors in
asexual and allosexual adults. The Journal of Sex Research, 1-11.
https://doi.org/10.1080/00224499.2022.2051161
Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender
persons. Journal of Homosexuality, 51(3), 53-69. https://doi.org/10.1300/j082v51n03_04
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 119
Cochran, S. D., & Mays, V. M. (2016). A strategic approach to eliminating sexual orientation-
related health disparities. American Journal of Public Health, 106(9), e4.
https://doi.org/10.2105/ajph.2016.303271
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress.
Journal of Health and Social Behavior, 24(4), 385. https://doi.org/10.2307/2136404
Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64(3),
170–180. https://doi.org/10.1037/a0014564
Conley-Fonda, B., & Leisher, T. (2018). Asexuality: Sexual health does not require sex. Sexual
Addiction & Compulsivity, 25(1), 6-11. https://doi.org/10.1080/10720162.2018.1475699
Craig, S. L., McInroy, L., McCready, L. T., & Alaggia, R. (2015). Media: A catalyst for
resilience in lesbian, gay, bisexual, transgender, and queer youth. Journal of LGBT Youth,
12(3), 254-275. https://doi.org/10.1080/19361653.2015.1040193
Crary, D. (2021, April 27). No big backlash for states passing anti-transgender laws. AP NEWS.
https://apnews.com/article/us-news-health-laws-legislature-bills-
5726fdeb8a5e7cf2c89a4a2d176e8a7f
Crenshaw, K. W. (1995). Mapping the margins: Intersectionality, identity politics, and violence
against women of color. In K. W. Crenshaw, N. Gotanda, G. Peller, & K. Thomas (Eds.),
Critical race theory: The key writings that formed the movement (pp. 357–383). The New
Press.
Crissman, H. P., Stroumsa, D., Kobernik, E. K., & Berger, M. B. (2019). Gender and frequent
mental distress: Comparing transgender and non-transgender individuals’ self-rated
mental health. Journal of Women’s Health, 28(2), 143–151.
https://doi.org/10.1089/jwh.2018.7411
Cuthbert, K. (2019). “When we talk about gender we talk about sex”: (A)sexuality and
(a)gendered subjectivities. Gender and Society, 33(6), 841–864.
https://doi.org/10.1177/0891243219867916
Davies, D. (1996). Pink therapy: A guide for counsellors and therapists working with lesbian,
gay, and bisexual clients. McGraw-Hill Education (UK).
Dawson, M., Scott, S., & McDonnell, L. (2018). ‘“Asexual” isn’t who I am’: The politics of
asexuality. Sociological Research Online, 23(2), 374–391.
https://doi.org/10.1177/1360780418757540
Decker, J. S. (2015). The invisible orientation: An introduction to asexuality. Simon & Schuster.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 120
De Cuypere, G. (2016). Mental health issues. In R. Ettner, S. Monstrey, & E.
Coleman (Eds.), Principles of transgender medicine and surgery (2nd ed., pp. 100–119).
Taylor and Francis.
dickey, l. m., Budge, S. L., Katz-Wise, S. L., & Garza, M. V. (2016). Health disparities in the
transgender community: Exploring differences in insurance coverage. Psychology of
Sexual Orientation and Gender Diversity, 3(3), 275-282.
https://doi.org/10.1037/sgd0000169
Dinno, A. (2015). Nonparametric pairwise multiple comparisons in independent groups using
Dunn's test. The Stata Journal: Promoting communications on statistics and Stata, 15(1),
292-300. https://doi.org/10.1177/1536867x1501500117
Dunlap, A. (2016). Changes in coming out milestones across five age cohorts. Journal of Gay &
Lesbian Social Services, 28(1), 20-38. https://doi.org/10.1080/10538720.2016.1124351
Dunn, O. J. (1964). Multiple comparisons using rank sums. Technometrics, 6(3), 241-252.
https://doi.org/10.1080/00401706.1964.10490181
Edwards, L. L., Torres Bernal, A., Hanley, S. M., & Martin, S. (2019). Resilience factors and
suicide risk for a sample of transgender clients. Family Process, 59(3), 1209–1224.
https://doi.org/10.1111/famp.12479
Everett, B. G., Steele, S. M., Matthews, A. K., & Hughes, T. L. (2019). Gender, race, and
minority stress among sexual minority women: An intersectional approach. Archives of
Sexual Behavior, 48(5), 1505–1517. https://doi.org/10.1007/s10508-019-1421-x
Factor, R., & Rothblum, E. (2008). Exploring gender identity and community among three
groups of transgender individuals in the United States: MTFs, FTMs, and genderqueers.
Health Sociology Review, 17(3), 235–253. https://doi.org/10.5172/hesr.451.17.3.235
Farrell, M. (2018). Exploring nonbinary transgender clients’ counseling experiences:
Empowerment in counseling [Doctoral dissertation, University of Missouri-Kansas City].
https://mospace.umsystem.edu/xmlui/bitstream/handle/10355/64518/Dissertation_2018_
Farrell.pdf?sequence=1&isAllowed=y
Fassinger, R. E., & Arseneau, J. R. (2007). “I’d rather get wet than be under that umbrella”:
Differentiating the experiences and identities of lesbian, gay, bisexual, and transgender
people. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling
and psychotherapy with lesbian, gay, bisexual, and transgender clients (pp. 19–49).
American Psychological Association.
Fattoracci, E. S., Revels-Macalinao, M., & Huynh, Q. (2021). Greater than the sum of racism
and heterosexism: Intersectional microaggressions toward racial/ethnic and sexual
minority group members. Cultural Diversity and Ethnic Minority Psychology, 27(2), 176-
188. https://doi.org/10.1037/cdp0000329
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 121
Feinberg, L. (1996). Transgender warriors: Making history from Joan of Arc to Dennis Rodman.
Beacon Press.
Feldman, J., Brown, G. R., Deutsch, M. B., Hembree, W., Meyer, W., Meyer-Bahlburg, H. F.,
Tangpricha, V., T'Sjoen, G., & Safer, J. D. (2016). Priorities for transgender medical and
health care research. Endocrinology & Diabetes and Obesity, 23(2), 180-187.
https://doi.org/10.1097/MED.0000000000000231
Fergus, S., & Zimmerman, M. A. (2005). Adolescent resilience: A framework for understanding
healthy development in the face of risk. Annual Review of Public Health, 26(1), 399–419.
https://doi.org/10.1146/annurev.publhealth.26.021304.144357
Fernandez, T., Godwin, A., Doyle, J., Verdin, D., Boone, H., Kirn, A., Benson, L., & Potvin, G.
(2016, June 26-29). More comprehensive and inclusive approaches to demographic data
collection [Paper presentation]. ASEE Annual Conference & Exposition 2016 New
Orleans, LA. https://doi.org/10.18260/p.25751
Field, A. (2017). Discovering statistics using IBM SPSS statistics. SAGE Publications.
Figueroa, W. S., & Zoccola, P. M. (2015). Individual differences of risk and resiliency in sexual
minority health: The roles of stigma consciousness and psychological hardiness.
Psychology of Sexual Orientation and Gender Diversity, 2(3), 329–338.
https://doi.org/10.1037/sgd0000114
Finch, H. (2005). Comparison of the performance of nonparametric and parametric MANOVA
test statistics when assumptions are violated. Methodology, 1(1), 27-38.
https://doi.org/10.1027/1614-1881.1.1.27
Fish, J. N., McInroy, L. B., Paceley, M. S., Williams, N. D., Henderson, S., Levine, D. S., &
Edsall, R. N. (2020). “I'm kinda stuck at home with unsupportive parents right now”:
LGBTQ youths' experiences with COVID-19 and the importance of online support.
Journal of Adolescent Health, 67(3), 450-452.
https://doi.org/10.1016/j.jadohealth.2020.06.002
Flanagan, S. K., & Peters, H. J. (2020). Asexual-identified adults: Interactions with health-care
practitioners. Archives of Sexual Behavior, 49(5), 1631–1643.
https://doi.org/10.1007/s10508-020-01670-6
Flore, J. (2014). Mismeasures of asexual desires. In K. J. Cerankowski & M. Milks (Eds.),
Asexualities: Feminist and queer perspectives (pp. 17–34). Routledge.
Foster, A. (2017). Measuring social invisibility and erasure: Development of the Asexual
Microaggressions Scale [Doctoral dissertation, Columbia University]. Columbia
Academic Commons. https://academiccommons.columbia.edu/doi/10.7916/D8M61XR3
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 122
Foster, A. B., Eklund, A., Brewster, M. E., Walker, A. D., & Candon, E. (2019). Personal agency
disavowed: Identity construction in asexual women of color. Psychology of Sexual
Orientation and Gender Diversity, 6(2), 127-137. https://doi.org/10.1037/sgd0000310
Foster, A. B., & Scherrer, K. S. (2014). Asexual-identified clients in clinical settings:
Implications for culturally competent practice. Psychology of Sexual Orientation and
Gender Diversity, 1(4), 422–430. https://doi.org/10.1037/sgd0000058
Fredrick, E. G., Mann, A. K., Brooks, B. D., & Hirsch, J. K. (2022). Anticipated to enacted:
Structural stigma against sexual and gender minorities following the 2016 presidential
election. Sexuality Research and Social Policy, 19(1), 345-354.
https://doi.org/10.1007/s13178-021-00547-0
Fredriksen-Goldsen, K. I., Cook-Daniels, L., Kim, H., Erosheva, E. A., Emlet, C. A., Hoy-
Ellis, C. P., Goldsen, J., & Muraco, A. (2013). Physical and mental health of transgender
older adults: An at-risk and underserved population. The Gerontologist, 54(3), 488–500.
https://doi.org/10.1093/geront/gnt021
Freedom for All Americans. (n.d.). LGBTQ Americans aren’t fully protected from discrimination
in 29 states. https://freedomforallamericans.org/states/
Frohard-Dourlent, H., Dobson, S., Clark, B. A., Doull, M., & Saewyc, E. M. (2017). “I would
have preferred more options”: Accounting for nonbinary youth in health research.
Nursing Inquiry, 24(1), e12150. https://doi.org/10.1111/nin.12150
Fuller, K. (2020). Lesbian, gay, and bisexuality from a cross-cultural perspective. In D. L.
Rowland & E. A. Jannini (Eds.), Cultural differences and the practice of sexual
medicine: A guide for sexual health practitioners (pp. 63-83). Springer Nature.
Fuller, K. A., & Riggs, D. W. (2018). Family support and discrimination and their relationship to
psychological distress and resilience amongst transgender people. International Journal
of Transgenderism, 19(4), 379–388. https://doi.org/10.1080/15532739.2018.1500966
Galupo, M. P., Henise, S. B., & Davis, K. S. (2014). Transgender microaggressions in the
context of friendship: Patterns of experience across friends’ sexual orientation and gender
identity. Psychology of Sexual Orientation and Gender Diversity, 1(4), 461–470.
https://doi.org/10.1037/sgd0000075
Gamarel, K. E., Reisner, S. L., Laurenceau, J., Nemoto, T., & Operario, D. (2014). Gender
minority stress, mental health, and relationship quality: A dyadic investigation of
transgender women and their cisgender male partners. Journal of Family Psychology,
28(4), 437–447. https://doi.org/10.1037/a0037171
Gazzola, S. B., & Morrison, M. A. (2012). Asexuality: An emergent sexual orientation. In T. G.
Morrison, M. A. Morrison, M. A. Carrigan, & D. T. McDermott (Eds.), Sexual minority
research in the new millennium (pp. 21–44). Nova Science.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 123
Gonzalez, C. A., Bockting, W. O., Beckman, L. J., & Durán, R. E. (2012). Agentic and
communal personality traits: Their associations with depression and resilience among
transgender women. Sex Roles, 67(9-10), 528–543. https://doi.org/10.1007/s11199-012-
0202-y
Gonzalez, K. A., Ramirez, J. L., & Galupo, M. P. (2018). Increase in GLBTQ minority stress
following the 2016 US presidential election. Journal of GLBT Family Studies, 14(1-2),
130-151. https://doi.org/10.1080/1550428x.2017.1420849
Government Equalities Office. (2018). National LGBT survey: Research report.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_
data/file/721704/LGBT-survey-research-report.pdf
Gower, A. L., Rider, G. N., Brown, C., McMorris, B. J., Coleman, E., Taliaferro, L. A., &
Eisenberg, M. E. (2018). Supporting transgender and gender diverse youth: Protection
against emotional distress and substance use. American Journal of Preventive Medicine,
55(6), 787–794. https://doi.org/10.1016/j.amepre.2018.06.030
Grant, J. M., Mottet, L. A., Tannis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011).
Injustice at every turn: A report of the National Transgender Discrimination Survey.
National Center for Transgender Equality; National Gay and Lesbian Task Force.
https://www.transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf
Graham, L. F., Crissman, H. P., Tocco, J., Hughes, L. A., Snow, R. C., & Padilla, M. B. (2014).
Interpersonal relationships and social support in transitioning narratives of Black
transgender women in Detroit. International Journal of Transgenderism, 15(2), 100–113.
https://doi.org/10.1080/15532739.2014.937042
Greaves, L. M., Barlow, F. K., Lee, C. H., Matika, C. M., Wang, W., Lindsay, C., Case, C. J.,
Sengupta, N. K., Huang, Y., Cowie, L. J., Stronge, S., Storey, M., De Souza, L.,
Manuela, S., Hammond, M. D., Milojev, P., Townrow, C. S., Muriwai, E., Satherley, N.,
… Sibley, C. G. (2016). The diversity and prevalence of sexual orientation self-labels in a
New Zealand national sample. Archives of Sexual Behavior, 46(5), 1325–1336.
https://doi.org/10.1007/s10508-016-0857-5
Greene, B., & Spivey, P. (2016). Sexual minority couples and families: Clinical considerations.
In S. Kelly (Ed.), Diversity in couple and family therapy: Ethnicities, sexualities, and
socioeconomics (pp. 181–201). ABC-CLIO.
Gridley, S. J., Crouch, J. M., Evans, Y., Eng, W., Antoon, E., Lyapustina, M., Schimmel-
Bristow, A., Woodward, J., Dundon, K., Schaff, R., McCarty, C., Ahrens, K., &
Breland, D. J. (2016). Youth and caregiver perspectives on barriers to gender-affirming
health care for transgender youth. Journal of Adolescent Health, 59(3), 254–261.
https://doi.org/10.1016/j.jadohealth.2016.03.017
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 124
Gupta, K. (2015). What does asexuality teach us about sexual disinterest? Recommendations for
health professionals based on a qualitative study with asexually identified people. Journal
of Sex & Marital Therapy, 43(1), 1–14. https://doi.org/10.1080/0092623x.2015.1113593
Gupta, K. (2018). Gendering asexuality and asexualizing gender: A qualitative study exploring
the intersections between gender and asexuality. Sexualities, 22(7-8), 1197–1216.
https://doi.org/10.1177/1363460718790890
Guz, S., Hecht, H. K., Kattari, S. K., Gross, E. B., & Ross, E. (2022). A scoping review of
empirical asexuality research in social science literature. Archives of Sexual Behavior.
https://doi.org/10.1007/s10508-022-02307-6
Harms, C. A., Cohen, L., Pooley, J. A., Chambers, S. K., Galvão, D. A., & Newton, R. U.
(2018). Quality of life and psychological distress in cancer survivors: The role of psycho‐
social resources for resilience. Psycho-Oncology, 28(2), 271–277.
https://doi.org/10.1002/pon.4934
Harms, C., Pooley, J. A., & Cohen, L. (2017). The protective factors for resilience scale (PFRS):
Development of the scale. Cogent Psychology, 4(1), 1400415.
https://doi.org/10.1080/23311908.2017.1400415
Harrison, J., Grant, J., & Herman, J. L. (2012). A gender not listed here: Genderqueers, gender
rebels, and otherwise in the National Transgender Discrimination Survey. Williams
Institute. https://williamsinstitute.law.ucla.edu/publications/genderqueers-genderrebels-
ntds/
Hatzenbuehler, M. L., McLaughlin, K. A., Keyes, K. M., & Hasin, D. S. (2010). The impact of
institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual
populations: A prospective study. American Journal of Public Health, 100(3), 452–459.
https://doi.org/10.2105/ajph.2009.168815
Henderson, E. R., Blosnich, J. R., Herman, J. L., & Meyer, I. H. (2019). Considerations on
sampling in transgender health disparities research. LGBT Health, 6(6), 267–270.
https://doi.org/10.1089/lgbt.2019.0069
Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with
transgender and gender nonconforming clients: An adaptation of the minority stress
model. Professional Psychology: Research and Practice, 43(5), 460–467.
https://doi.org/10.1037/a0029597
Herbenick, D., Reece, M., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, J. D. (2010).
Sexual behavior in the United States: Results from a national probability sample of men
and women ages 14–94. The Journal of Sexual Medicine, 7(s5), 255-265.
https://doi.org/10.1111/j.1743-6109.2010.02012.x
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 125
Herek, G. M. (2009). Sexual stigma and sexual prejudice in the United States: A conceptual
framework. Contemporary Perspectives on Lesbian, Gay, and Bisexual Identities, 65-
111. https://doi.org/10.1007/978-0-387-09556-1_4
Herman, J. L., Flores, A. R., & O'Neill, K. K. (2016). How many adults identify as transgender
in the United States? The Williams Institute.
https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
Herrick, A. L., Stall, R., Goldhammer, H., Egan, J. E., & Mayer, K. H. (2013). Resilience as a
research framework and as a cornerstone of prevention research for gay and bisexual
men: Theory and evidence. AIDS and Behavior, 18(1), 1–9.
https://doi.org/10.1007/s10461-012-0384-x
Hides, L., Lubman, D. I., Devlin, H., Cotton, S., Aitken, C., Gibbie, T., & Hellard, M. (2007).
Reliability and validity of the Kessler 10 and Patient Health Questionnaire among
injecting drug users. Australian & New Zealand Journal of Psychiatry, 41(2), 166–168.
https://doi.org/10.1080/00048670601109949
Hille, J. J., Simmons, M. K., & Sanders, S. A. (2019). “Sex” and the ace spectrum: Definitions of
sex, behavioral histories, and future interest for individuals who identify as asexual,
graysexual, or demisexual. The Journal of Sex Research, 57(7), 813–823.
https://doi.org/10.1080/00224499.2019.1689378
Hinderliter, A. (2013). How is asexuality different from hypoactive sexual desire disorder?
Psychology and Sexuality, 4(2), 167-178. https://doi.org/10.1080/19419899.2013.774165
Hirschfeld, M. (2003). Transvestites: The erotic drive to cross-dress (M. A. Lombardi-Nash,
Trans.). Prometheus Books. (Original work published 1910)
Holt, V., Skagerberg, E., & Dunsford, M. (2016). Young people with features of gender
dysphoria: Demographics and associated difficulties. Clinical Child Psychology and
Psychiatry, 21(1), 108–118. https://doi.org/10.1177/1359104514558431
Horne, S. G., McGinley, M., Yel, N., & Maroney, M. R. (2022). The stench of bathroom bills
and anti-transgender legislation: Anxiety and depression among transgender, nonbinary,
and cisgender LGBQ people during a state referendum. Journal of Counseling
Psychology, 69(1), 1-13. https://doi.org/10.1037/cou0000558
Hoyt, W. T., Imel, Z. E., & Chan, F. (2008). Multiple regression and correlation techniques:
Recent controversies and best practices. Rehabilitation Psychology, 53(3), 321–339.
https://doi.org/10.1037/a0013021
Hughto, J. M., Pletta, D., Gordon, L., Cahill, S., Mimiaga, M. J., & Reisner, S. L. (2021).
Negative transgender-related media messages are associated with adverse mental health
outcomes in a multistate study of transgender adults. LGBT Health, 8(1), 32-41.
https://doi.org/10.1089/lgbt.2020.0279
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 126
Human Rights Campaign. (2019). 2019 State Equality Index.
https://www.hrc.org/resources/state-equality-index
Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people:
Building a foundation for better understanding. The National Academies Press.
https://www.ncbi.nlm.nih.gov/books/NBK64806/pdf/Bookshelf_NBK64806.pdf
Jackson, S. D., Mohr, J. J., Sarno, E. L., Kindahl, A. M., & Jones, I. L. (2020). Intersectional
experiences, stigma-related stress, and psychological health among Black LGBQ
individuals. Journal of Consulting and Clinical Psychology, 88(5), 416-428.
https://doi.org/10.1037/ccp0000489
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report
of the 2015 U.S. Transgender Survey. National Center for Transgender Equality.
https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
Johnson, M. T. (1977). Asexual autoerotic women: Two invisible groups. In H. L. Gochros &
J. S. Gochros (Eds.), The sexually oppressed (pp. 96–109). Association Press.
Jones, C., Hayter, M., & Jomeen, J. (2017). Understanding asexual identity as a means to
facilitate culturally competent care: A systematic literature review. Journal of Clinical
Nursing, 26(23-24), 3811–3831. https://doi.org/10.1111/jocn.13862
Jones, B. A., Bowe, M., McNamara, N., Guerin, E., & Carter, T. (2021). Exploring the mental
health experiences of young trans and gender diverse people during the COVID-19
pandemic. International Journal of Transgender Health, 1-13.
https://doi.org/10.1080/26895269.2021.1890301
Kattari, S. K., Walls, N. E., Speer, S. R., & Kattari, L. (2016). Exploring the relationship
between transgender-inclusive providers and mental health outcomes among
transgender/gender variant people. Social Work in Health Care, 55(8), 635–650.
https://doi.org/10.1080/00981389.2016.1193099
Kazdin, A. E. (2017). Research design in clinical psychology (5th ed.). Pearson.
Kelleher, S., Murphy, M., & Su, X. (2022). Asexual identity development and internalisation: A
scoping review of quantitative and qualitative evidence. Psychology & Sexuality, 1-28.
https://doi.org/10.1080/19419899.2022.2057867
Kenagy, G. P., & Bostwick, W. B. (2005). Health and social service needs of transgender people
in Chicago. International Journal of Transgenderism, 8(2-3), 57–66.
https://doi.org/10.1300/j485v08n02_06
Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S.-L. T.,
Walters, E. E., & Zaslavsky, A. M. (2002). Short screening scales to monitor population
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 127
prevalences and trends in non-specific psychological distress. Psychological Medicine,
32(6), 959–976. https://doi.org/10.1017/s0033291702006074
Kessler, R. C., Barker, P. R., Colpe, L. J., Epstein, J. F., Gfroerer, J. C., Hiripi, E., Howes, M. J.,
Normand, S.-L. T., Manderscheid, R. W., Walters, E. E., & Zaslavsky, A. M. (2003).
Screening for serious mental illness in the general population. Archives of General
Psychiatry, 60(2), 184–189. https://doi.org/10.1001/archpsyc.60.2.184
Khan, L. (2013). Transgender health at the crossroads: Legal norms, insurance markets, and the
threat of healthcare reform. Yale Journal of Health Policy Law and Ethics, 11(2), Article
22136012.
https://pubmed.ncbi.nlm.nih.gov/22136012/
Kim, E. (2014). Asexualities and disabilities in constructing sexual normalcy. In K. J.
Cerankowski & M. Milks (Eds.), Asexualities: Feminist and queer perspectives (pp. 249–
282). Routledge.
Kim, J. H. (2019). Multicollinearity and misleading statistical results. Korean Journal of
Anesthesiology, 72(6), 558-569. https://doi.org/10.4097/kja.19087
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male.
Indiana University Press.
Koken, J. A., Bimbi, D. S., & Parsons, J. T. (2009). Experiences of familial acceptance-rejection
among transwomen of color. Journal of Family Psychology, 23(6), 853–860.
https://doi.org/10.1037/a0017198
Kcomt, L., Gorey, K. M., Barrett, B. J., & McCabe, S. E. (2020). Healthcare avoidance due to
anticipated discrimination among transgender people: A call to create trans-affirmative
environments. SSM - Population Health, 11, 100608.
https://doi.org/10.1016/j.ssmph.2020.100608
Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Löwe, B. (2007). Anxiety
disorders in primary care: Prevalence, impairment, comorbidity, and detection. Annals of
Internal Medicine, 146(5), 317–325. https://doi.org/10.7326/0003-4819-146-5-
200703060-00004
Kwon, P. (2013). Resilience in lesbian, gay, and bisexual individuals. Personality and Social
Psychology Review, 17(4), 371–383. https://doi.org/10.1177%2F1088868313490248
Kyweluk, M. A., Sajwani, A., & Chen, D. (2018). Freezing for the future: Transgender youth
respond to medical fertility preservation. International Journal of Transgenderism, 19(4),
401-416. https://doi.org/10.1080/15532739.2018.1505575
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 128
Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and
psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4),
357–361. https://doi.org/10.1037/0033-3204.38.4.357
Lance, C. E., & Vandenberg, R. J. (2009). Introduction. In C. E. Lance & R. J.
Vandenberg (Eds.), Statistical and methodological myths and urban legends: Doctrine,
verity and fable in organizational and social sciences (pp. 1-4). Routledge.
Lang, N. (2021, February 17). The Equality Act could be tough to pass, even with Democrats
controlling Senate. Them. https://www.them.us/story/equality-act-tough-pass-even-with-
democrats-controlling-senate
Lee, D. K. (2020). Data transformation: A focus on the interpretation. Korean Journal of
Anesthesiology, 73(6), 503-508. https://doi.org/10.4097/kja.20137
Lefevor, G. T., Boyd-Rogers, C. C., Sprague, B. M., & Janis, R. A. (2019). Health disparities
between genderqueer, transgender, and cisgender individuals: An extension of minority
stress theory. Journal of Counseling Psychology, 66(4), 385–395.
https://doi.org/10.1037/cou0000339
Lelutiu-Weinberger, C., & Pachankis, J. E. (2017). Acceptability and preliminary efficacy of a
lesbian, gay, bisexual, and transgender-affirmative mental health practice training in a
highly stigmatizing national context. LGBT Health, 4(5), 360–370.
https://doi.org/10.1089/lgbt.2016.0194
León, E., Neipp López, M. C., & Nuñez, R. M. (2020). Psychometric properties of the Spanish
version of the Protective Factors of Resilience Scale (PFRS). Anales de Psicología,
36(3), 468–474. https://doi.org/10.6018/analesps.406231
Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender
identity development. Journal of Homosexuality, 61(12), 1727–1758.
https://doi.org/10.1080/00918369.2014.951262
Leyva, V. L., Breshears, E. M., & Ringstad, R. (2014). Assessing the efficacy of LGBT cultural
competency training for aging services providers in California’s Central Valley. Journal
of Gerontological Social Work, 57(2-4), 335-348.
https://doi.org/10.1080/01634372.2013.872215
Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and self-harm in lesbian, gay, bisexual, and
transgender youth. American Journal of Preventive Medicine, 42(3), 221–228.
https://doi.org/10.1016/j.amepre.2011.10.023
Lombardi, E. L., Wilchins, R. A., Priesing, D., & Malouf, D. (2002). Gender violence. Journal of
Homosexuality, 42(1), 89–101. https://doi.org/10.1300/J082v42n01_05
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 129
MacInnis, C. C., & Hodson, G. (2012). Intergroup bias toward “Group X”: Evidence of
prejudice, dehumanization, avoidance, and discrimination against asexuals. Group
Processes & Intergroup Relations, 15(6), 725–743.
https://doi.org/10.1177/1368430212442419
MacNeela, P., & Murphy, A. (2014). Freedom, invisibility, and community: A qualitative study
of self-identification with asexuality. Archives of Sexual Behavior, 44(3), 799–812.
https://doi.org/10.1007/s10508-014-0458-0
Mahalanobis, P. C. (1936). On the generalised distance in statistics. Proceedings of the National
Institute of Sciences of India, 2(1), 49-55.
Mahon, C. P., Pachankis, J. E., Kiernan, G., & Gallagher, P. (2020). Risk and protective factors
for social anxiety among sexual minority individuals. Archives of Sexual Behavior, 50(3),
1015-1032. https://doi.org/10.1007/s10508-020-01845-1
Mara, C. A., & Peugh, J. L. (2020). Validity of data collected from randomized behavioral
clinical trials during the COVID-19 pandemic. Journal of Pediatric Psychology, 45(9),
971-976. https://doi.org/10.1093/jpepsy/jsaa078
Martin, J. I., & Meezan, W. (2003). Applying ethical standards to research and evaluations
involving lesbian, gay, bisexual, and transgender populations. Journal of Gay & Lesbian
Social Services, 15(1-2), 181–201. https://doi.org/10.1300/j041v15n01_12
Masten, A. S. (2007). Resilience in developing systems: Progress and promise as the fourth wave
rises. Development and Psychopathology, 19(3), 921–930.
https://doi.org/10.1017/s0954579407000442
Masten, A. S., & Reed, M. J. (2002). Resilience in development. In C. R. Snyder & S. J. Lopez
(Eds.) Handbook of positive psychology (pp. 74–88). Oxford University Press.
Matsuno, E., Webb, A., Budge, S., Krishnan, M., & Balsam, K. (2017). Nonbinary gender
identities. Society for the Psychology of Sexual Orientation and Gender Identity.
https://www.apadivisions.org/division-44/resources/nonbinary-fact-sheet.pdf
McAleavey, A. A., Castonguay, L. G., & Locke, B. D. (2011). Sexual orientation minorities in
college counseling: Prevalence, distress, and symptom profiles. Journal of College
Counseling, 14(2), 127–142. https://doi.org/10.1002/j.2161-1882.2011.tb00268.x
McConnell, E. A., Janulis, P., Phillips, G., Truong, R., & Birkett, M. (2018). Multiple minority
stress and LGBT community resilience among sexual minority men. Psychology of
Sexual Orientation and Gender Diversity, 5(1), 1-12. https://doi.org/10.1037/sgd0000265
McInroy, L. B. (2019). Building connections and slaying basilisks: Fostering support, resilience,
and positive adjustment for sexual and gender minority youth in online fandom
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 130
communities. Information, Communication & Society, 23(13), 1874–1891.
https://doi.org/10.1080/1369118x.2019.1623902
McInroy, L. B., Beaujolais, B., Leung, V. W., Craig, S. L., Eaton, A. D., & Austin, A. (2020).
Comparing asexual and non-asexual sexual minority adolescents and young adults:
Stressors, suicidality and mental and behavioural health risk outcomes. Psychology &
Sexuality, 1–17. https://doi.org/10.1080/19419899.2020.1806103
McInroy, L. B., & Craig, S. L. (2015). Transgender representation in offline and online media:
LGBTQ youth perspectives. Journal of Human Behavior in the Social Environment,
25(6), 606-617. https://doi.org/10.1080/10911359.2014.995392
McInroy, L. B., & Craig, S. L. (2018). Online fandom, identity milestones, and self-
identification of sexual/gender minority youth. Journal of LGBT Youth, 15(3), 179-196.
https://doi.org/10.1080/19361653.2018.1459220
Meier, S. C., & Labuski, C. M. (2013). The demographics of the transgender population. In
A. K. Baumle (Ed.), International handbook on the demography of sexuality (pp. 289–
327). Springer Netherlands.
Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social
Behavior, 36(1), 38–56. https://doi.org/10.2307/2137286
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual
populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5),
674–697. https://doi.org/10.1037/0033-2909.129.5.674
Meyer, I. H. (2010). Identity, stress, and resilience in lesbians, gay men, and bisexuals of color.
The Counseling Psychologist, 38(3), 442–454.
https://doi.org/10.1177/0011000009351601
Meyer, I. H. (2015). Resilience in the study of minority stress and health of sexual and gender
minorities. Psychology of Sexual Orientation and Gender Diversity, 2(3), 209–213.
https://doi.org/10.1037/sgd0000132
Meyer, I. H., Brown, T. T., Herman, J. L., Reisner, S. L., & Bockting, W. O. (2017).
Demographic characteristics and health status of transgender adults in select US regions:
Behavioral Risk Factor Surveillance System, 2014. American Journal of Public Health,
107(4), 582–589. https://doi.org/10.2105/AJPH.2016.303648
Milks, M., & Cerankowski, K. J. (2014). Introduction: Why asexuality? Why now? In K. J.
Cerankowski & M. Milks (Eds.), Asexualities: Feminist and queer perspectives (pp. 1–
14). Routledge.
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 131
Miller, T. (2011). Analysis of the 2011 Asexual Awareness Week Community Census. Asexual
Awareness Week. https://asexualcensus.files.wordpress.com/2017/04/aaw-2011-survey-
results.pdf
Millet, N., Longworth, J., & Arcelus, J. (2017). Prevalence of anxiety symptoms and disorders in
the transgender population: A systematic review of the literature. International Journal of
Transgenderism, 18(1), 27–38. https://doi.org/10.1080/15532739.2016.1258353
Mink, M. D., Lindley, L. L., & Weinstein, A. A. (2014). Stress, stigma, and sexual minority
status: The intersectional ecology model of LGBTQ health. Journal of Gay & Lesbian
Social Services, 26(4), 502–521. https://doi.org/10.1080/10538720.2014.953660
Mitchell, H., & Hunnicutt, G. (2018). Challenging accepted scripts of sexual “normality”:
Asexual narratives of non-normative identity and experience. Sexuality & Culture, 23(2),
507–524. https://doi.org/10.1007/s12119-018-9567-6
Mizock, L., & Mueser, K. T. (2014). Employment, mental health, internalized stigma, and
coping with transphobia among transgender individuals. Psychology of Sexual
Orientation and Gender Diversity, 1(2), 146-158. https://doi.org/10.1037/sgd0000029
Mohr, J., & Fassinger, R. (2000). Measuring dimensions of lesbian and gay male experience.
Measurement and Evaluation in Counseling and Development, 33(2), 66–90.
https://doi.org/10.1080/07481756.2000.12068999
Mollet, A. L., & Lackman, B. R. (2018). Asexual borderlands: Asexual collegians’ reflections on
inclusion under the LGBTQ umbrella. Journal of College Student Development, 59(5),
623–628. https://doi.org/10.1353/csd.2018.0058
Moody, C., & Smith, N. G. (2013). Suicide protective factors among trans adults. Archives of
Sexual Behavior, 42(5), 739-752. https://doi.org/10.1007/s10508-013-0099-8
Morandini, J. S., Blaszczynski, A., Ross, M. W., Costa, D. S., & Dar-Nimrod, I. (2015).
Essentialist beliefs, sexual identity uncertainty, internalized homonegativity and
psychological wellbeing in gay men. Journal of Counseling Psychology, 62(3), 413–424.
https://doi.org/10.1037/cou0000072
Mukerjee, R., Wesp, L., Singer, R., & Menkin, D. (Eds.), Clinician’s guide to LGBTQIA+ care:
Cultural safety and social justice in primary, sexual, and reproductive healthcare.
Springer Publishing Company.
Mustanski, B. S., Garofalo, R., & Emerson, E. M. (2010). Mental health disorders, psychological
distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender
youths. American Journal of Public Health, 100(12), 2426–2432.
https://doi.org/10.2105/ajph.2009.178319
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 132
Nadal, K. L., Davidoff, K. C., Davis, L. S., & Wong, Y. (2014). Emotional, behavioral, and
cognitive reactions to microaggressions: Transgender perspectives. Psychology of Sexual
Orientation and Gender Diversity, 1(1), 72-81. https://doi.org/10.1037/sgd0000011
Namaste, V. (2000). Invisible lives: The erasure of transsexual and transgendered people.
University of Chicago Press.
Nemoto, T., Bödeker, B., & Iwamoto, M. (2011). Social support, exposure to violence and
transphobia, and correlates of depression among male-to-female transgender women with
a history of sex work. American Journal of Public Health, 101(10), 1980–1988.
https://doi.org/10.2105/ajph.2010.197285
Nemoto, T., Operario, D., Keatley, J., Han, L., & Soma, T. (2004). HIV risk behaviors among
male-to-female transgender persons of color in San Francisco. American Journal of
Public Health, 94(7), 1193–1199. https://doi.org/10.2105/ajph.94.7.1193
Newcomb, M. E., Hill, R., Buehler, K., Ryan, D. T., Whitton, S. W., & Mustanski, B. (2020).
High burden of mental health problems, substance use, violence, and gender related
psychosocial factors in transgender, nonbinary, and gender diverse youth and young
adults. Archives of Sexual Behavior, 49(2), 645–659. https://doi.orgwg/10.1007/s10508-
019-01533-9
Newcomb, M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing mental
health problems: A meta-analytic review. Clinical Psychology Review, 30(8), 1019–1029.
https://doi.org/10.1016/j.cpr.2010.07.003
Noelle, M. (2002). The ripple effect of the Matthew Shepard murder. American Behavioral
Scientist, 46(1), 27-50. https://doi.org/10.1177/0002764202046001004
Nuttbrock, L., Bockting, W., Rosenblum, A., Hwahng, S., Mason, M., Macri, M., & Becker, J.
(2014). Gender abuse and major depression among transgender women: A prospective
study of vulnerability and resilience. American Journal of Public Health, 104(11), 2191–
2198. https://doi.org/10.2105/ajph.2013.301545
Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J.
(2010). Psychiatric impact of gender-related abuse across the life course of male-to-
female transgender persons. Journal of Sex Research, 47(1), 12–23.
https://doi.org/10.1080/00224490903062258
Olson, K. R., Key, A. C., & Eaton, N. R. (2015). Gender cognition in transgender children.
Psychological Science, 26(4), 467–474. https://doi.org/10.1177/0956797614568156
Pachankis, J. E., & Goldfried, M. R. (2004). Clinical issues in working with lesbian, gay, and
bisexual clients. Psychotherapy: Theory, Research, Practice, Training, 41(3), 227-246.
https://doi.org/10.1037/0033-3204.41.3.227
PSYCHOLOGICAL DISTRESS OF ASEXUAL TGNC INDIVIDUALS 133
Parent, M. C., & Silva, K. (2018). Critical consciousness moderates the relationship between
transphobia and “bathroom bill” voting. Journal of Counseling Psychology, 65(4), 403–
412. https://doi.org/10.1037/cou0000270
Parodi, K. B., Holt, M. K., Green, J. G., Katz-Wise, S. L., Shah, T. N., Kraus, A. D., & Xuan, Z.
(2022). Associations between school-related factors and mental health among transgender
and gender diverse youth. Journal of School Psychology, 90, 135-149.
https://doi.org/10.1016/j.jsp.2021.11.004
Pepping, C. A., Lyons, A., & Morris, E. M. (2018). Affirmative LGBT psychotherapy:
Outcomes of a therapist training protocol. Psychotherapy, 55(1), 52-62.
https://doi.org/10.1037/pst0000149
Pflum, S. R., Testa, R. J., Balsam, K. F., Goldblum, P. B., & Bongar, B. (2015). Social support,
trans community connectedness, and mental health symptoms among transgender and
gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity,
2(3), 281–286. https://doi.org/10.1037/sgd0000122
Poquiz, J. L., Coyne, C. A., Garofalo, R., & Chen, D. (2021). Comparison of gender minority
stress and resilience among transmasculine, transfeminine, and nonbinary adolescents
and young adults. Journal of Adolescent Health, 68(3), 615–618.
https://doi.org/10.1016/j.jadohealth.2020.06.014
Poston, D., & Baumle, A. (2010). Patterns of asexuality in the United States. Demographic
Research, 23(18), 509–530. https://doi.org/10.4054/demres.2010.23.18
Pratt-Chapman, M. L., Eckstrand, K., Robinson, A., Beach, L. B., Kamen, C.,
Keuroghlian, A. S., Cook, S., Radix, A., Bidell, M. P., Bruner, D., & Margolies, L.
(2022). Developing standards for cultural competency training for health care providers
to care for lesbian, gay, bisexual, transgender, queer, intersex, and asexual persons:
Consensus recommendations from a national panel. LGBT Health, 9(5), 340-347.
https://doi.org/10.1089/lgbt.2021.0464
Prause, N., & Graham, C. A. (2007). Asexuality: Classification and characterization. Archives of
Sexual Behavior, 36(3), 341–356. https://doi.org/10.1007/s10508-006-9142-3
Przybylo, E. (2014). Masculine doubt and sexual wonder: Asexually-identified men talk about
their (a)sexualities. In K. J. Cerankowski & M. Milks (Eds.), Asexualities: Feminist and
queer perspectives (pp. 225–248). Routledge.
Puckett, J. A., Brown, N. C., Dunn, T., Mustanski, B., & Newcomb, M. E. (2020a). Perspectives
from transgender and gender diverse people on how to ask about gender. LGBT Health,
7(6), 305-311. https://doi.org/10.1089/lgbt.2019.0295
Puckett, J. A., Maroney, M. R., Wadsworth, L. P., Mustanski, B., & Newcomb, M. E. (2020b).
Coping with discrimination: The insidious effects of gender minority stigma on